Schedule for Rating Disabilities; The Cardiovascular System

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AE40

Schedule for Rating Disabilities; The Cardiovascular System

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends that portion of the Department of

Veterans Affairs (VA) Schedule for Rating Disabilities addressing the

cardiovascular system. The effect of this action is to update the

cardiovascular system portion of the rating schedule to ensure that it

uses current medical terminology and unambiguous criteria, and that it

reflects medical advances that have occurred since the last review.

EFFECTIVE DATE: This amendment is effective January 12, 1998.

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

Regulations Staff (213A), Compensation and Pension Service, Veterans

Benefits Administration, Department of Veterans Affairs, 810 Vermont

Avenue NW, Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of the

rating schedule, VA published, in the Federal Register of January 19,

1993 (58 FR 4954-60), a proposal to amend 38 CFR 4.100, 4.101, 4.102,

and 4.104. Interested persons were invited to submit written comments,

suggestions, or objections on or before March 22, 1993. We received

comments from the Disabled American Veterans, the Veterans of Foreign

Wars, the Paralyzed Veterans of America, the American Legion, and

several VA employees.

One commenter, stating that the primary objective of the review is

to update the medical terminology and criteria used to evaluate

disabilities rather than to amend the percentage evaluations,

contended, without being specific, that a substantial number of the

proposed changes go beyond the stated purpose and expressed general

opposition to any changes that are inconsistent with the stated

objective. The commenter also stated that the proposed criteria retain,

and in some cases expand upon, the vague, indefinite, and arbitrary

elements previously found in the schedule and felt that substantial

revision of the proposed rules is required.

The purpose of the review was to update the cardiovascular system

portion of the rating schedule to ensure that it uses current medical

terminology and unambiguous criteria, and that it reflects medical

advances that have occurred since the last review. The proposed

revisions published January 19, 1993, were intended to update the

medical terminology; revise the criteria, including the length of

convalescence evaluations, based on medical advances; and make criteria

more objective, i.e., less ambiguous and, thereby, assure more

consistent ratings. These proposed changes were consistent with the

stated purposes of the revision. However, since establishing less

ambiguous criteria to assure consistent evaluations is one of the

purposes of this revision, and a number of commenters stated that the

proposed criteria contained language that is too subjective to provide

effective guidance in evaluating cardiovascular disabilities, we have

further revised the proposed evaluation criteria to eliminate

indefinite terminology and establish more objective and quantifiable

criteria wherever possible. These changes will be discussed in detail

under the individual codes affected.

One commenter suggested that the proposed criteria will

discriminate against veterans of Desert Storm and future veterans

because their conditions will be evaluated under criteria that he

perceived as less generous than those in the prior rating schedule.

Significant medical advances, including new surgical and anesthetic

techniques, new medications, and earlier diagnoses, have occurred,

which we must take into account in revising the rating schedule. Doing

so is, in fact, one of the primary reasons for conducting this review.

Since recently discharged veterans clearly benefit from the application

of these new techniques, in our judgment they are not discriminated

against by having their disabilities evaluated under criteria which

reflect the effects of these same medical advances.

One commenter objected that the rating schedule fails to take into

consideration the disabling effects of the veteran's shortened life

expectancy.

To consider a factor so far removed from ``the average impairments

of earning capacity'' as the effect of various conditions on life

expectancy would clearly exceed the parameters established by Congress

in 38 U.S.C. 1155.

One commenter, citing a statistical economic validation study from

the 1960s, implied that statistical studies may justify increased

disability evaluations.

The statute (38 U.S.C. 1155) authorizing establishment of the

rating 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

based on that study were not adopted.

One commenter agreed that ambiguous words such as ``severe'' should

be deleted, but cautioned against making the evaluation criteria too

objective.

Providing clear and objective criteria is the best way to assure

that disabilities will be evaluated fairly and consistently. Judgment

and flexibility cannot be eliminated from the evaluation process,

however, because patients do not commonly present as textbook models of

disease, and rating agencies have the task of assessing which

evaluation level best represents the overall disability picture. (See

Sec. 4.7.)

The previous schedule provided convalescence evaluations for six

[[Page 65208]]

months for the following conditions: rheumatic heart disease (DC 7000);

arteriosclerotic heart disease, following coronary occlusion (DC 7005);

myocardial infarction (DC 7006); and soft tissue sarcoma (of vascular

origin) (DC 7123). It provided convalescence evaluations for one year

for the following conditions: Auriculoventricular block, with

implantation of a pacemaker (DC 7015); heart valve replacement (DC

7016); coronary artery bypass (DC 7017); and aortic aneurysm, following

surgical correction (DC 7110). We proposed to change the duration of

convalescence evaluations for DC 7000, DC 7005, and DC 7006 to three

months; for DC 7018 (pacemaker implantation, formerly DC 7015) to two

months; and for DC 7017 to three months. We proposed an indefinite

period of convalescence evaluation with an examination at six months

for DC 7016, DC 7110, DC 7011 (now ventricular arrhythmias), DC 7111

(aneurysm of any large artery), and DC 7123. We also proposed an

indefinite period of convalescence evaluation, but with an examination

at one year, for cardiac transplantation (DC 7019).

One commenter stated that VA should justify the proposed changes in

periods of convalescence evaluation by citing medical experts or texts.

A report from Jefferson Medical College that included a clinical

review of the cardiovascular portion of the rating schedule and

recommendations for changes was available to us when we undertook the

revision of this body system. In addition, we received advice from the

Veterans Health Administration and consulted standard medical texts

such as ``Cecil Textbook of Medicine'' (James B. Wyngaarden, M.D. et

al. eds., 19th ed. 1992), ``Heart Disease'' (Eugene Braunwald, M.D.

ed., 4th ed. 1992), and ``The Heart'' (J. Willis Hurst, M.D. et al.

eds., 7th ed. 1990). We published the proposed revision only after

reviewing all of these sources of information. We have provided

specific citations supporting many of the changes in the length of

convalescence evaluations later in this document under the discussions

of convalescence evaluation periods that have been changed.

One commenter stated that the proposed periods of convalescence

evaluation do not represent the average impairment, but only the

optimal recovery times. This commenter also stated that the changes in

the duration of convalescence evaluations do not take into account

advanced age, poor state of health, or the presence of etiologically

related or concomitant disease.

The periods of convalescence evaluation we have established

reflect, according to the sources noted above, the average periods of

recovery needed by the average person following certain procedures and

illnesses. These periods can be extended, when medically warranted,

under the authority of 38 CFR 4.29 and 4.30.

One commenter said that the proposed changes in the length of

convalescence evaluations appear to have been developed from a purely

economic perspective.

As previously discussed, revisions to periods of convalescence

evaluations were based on medical considerations rather than cost

projections.

One of the commenters suggested that where the length of

convalescence evaluations has been reduced to two, three, or six

months, all claims should be referred to the Adjudication Officer for a

possible extension of the convalescence rating under 38 CFR 4.30(b)(2).

The rating agency itself has the authority to extend the period of

convalescence evaluations for up to three months under the provisions

of Sec. 4.30; the approval of the Adjudication Officer is required only

when extending a convalescence evaluation for a longer period.

Referring claims to the Adjudication Officer when the medical evidence

does not warrant any extension, or when the rating agency can extend

the evaluation for a sufficient period on its own authority, would

cause needless delay, and we have made no change based on this

suggestion.

Several commenters objected to indefinite periods of convalescence

evaluation with a mandatory VA examination at a prescribed time. In our

judgment, however, this method of determining the length of the total

evaluation is both fairer and more accurate than assigning a total

evaluation for a specified length of time, since the evaluation will be

based on actual residual disability as documented by the examination,

and the veteran will receive advance notice of any change and have the

opportunity to submit additional evidence showing that the change is

not warranted.

One set of comments reflected the view that applying Sec. 3.105(e)

to indefinite periods of convalescence evaluations will cause

significant administrative problems and, in some instances,

significantly lengthen the period for which a convalescence evaluation

is assigned. These concerns appear to be based on the assumption that

if medical information justifying a certain period of convalescence

evaluation is not submitted until months or even years after the event,

the condition must be evaluated as totally disabling from the date

entitlement is established, through the entire intervening period, and

until such time as an examination can be performed, advance notice be

provided, and the effective date provisions of Sec. 3.105(e) be

observed.

Section 3.105(e) applies only to reductions in ``compensation

payments currently being made;'' it does not apply in cases where a

total evaluation is both assigned and reduced retroactively. We have

established convalescence evaluations for indefinite periods under

other portions of the rating schedule (See DC 7528, malignant neoplasms

of the genitourinary system, in 38 CFR 4.115b and DC 7627, malignant

neoplasms of gynecological system or breast, in 38 CFR 4.116), some

having been in effect for over two years, and there is no evidence that

they cause the type of administrative problems that the commenters

foresee.

There were three introductory sections to the cardiovascular system

in the previous rating schedule. Section 4.100, Necessity for complete

diagnosis, named common types of heart disease and discussed the need

for accurate diagnosis. Section 4.101, Rheumatic heart disease,

discussed the course of rheumatic heart disease, the significance of a

diagnosis of mitral insufficiency, possible etiologies for later

developing aortic insufficiency, and the need for accurate diagnosis of

a service-connected condition. Section 4.102, Varicose veins and

phlebitis, discussed the need to determine impairment of deep

circulation due to varicosities and included a requirement to assign a

higher evaluation when there is phlebitis or deep impairment of

circulation. We proposed to retitle the introductory sections: 4.100,

as ``Forms of heart disorder;'' 4.101, as ``Hypertension;'' and 4.102,

as ``Varicose veins.'' We proposed to include in Sec. 4.100 a list of

common forms of heart abnormalities, a discussion of how to evaluate

service-connected valvular heart disease or arrhythmia in the presence

of nonservice-connected arteriosclerotic heart disease, and a statement

that the identification of coronary artery disease (without occlusion

or thrombosis) early in service is not a basis for service connection,

but that any sudden development of coronary occlusion or thrombosis

during service would be service-connected. However, as explained below,

we have either deleted or relocated all of the material we had proposed

to include in Secs. 4.100, 4.101,

[[Page 65209]]

and 4.102, and we have, therefore, removed those sections and reserved

them for future use.

One commenter suggested that we remove all material in Secs. 4.100,

4.101, and 4.102 that refer to the issue of service connection because

it is inappropriate to place criteria for determining entitlement to

service connection in the rating schedule. A second commenter suggested

that the material about the identification of coronary artery disease

early in service not being a basis for service connection should be

removed because the provision violates the statutory presumption of

soundness at induction as set forth in 38 U.S.C. 1111.

The rules governing determinations of service connection are found

in the regulations beginning at 38 CFR 3.303, rather than in the rating

schedule, which is a guide to evaluating disabilities. We agree that

rules affecting determinations of service connection are inappropriate

in the rating schedule, and we have removed that portion of the

material in Sec. 4.100 that addressed the issue of service connection

for coronary artery disease for that reason. We have also removed other

provisions of Secs. 4.101 and 4.102 that addressed service connection

for cardiovascular conditions, as discussed below.

We had proposed including in Sec. 4.102, varicose veins, a

provision from VA's Adjudication Procedures Manual, M21-1, Part VI,

that if varicose veins developed during active service in one leg,

varicose veins developing in the other leg within three years, in the

absence of an intercurrent cause, will also be service-connected.

However, in response to this comment, we have determined that since it

addresses the issue of service connection, it is not appropriate in the

rating schedule, and we have removed it.

Two commenters suggested that these introductory sections specify

which cardiovascular diseases should be service-connected when they

develop subsequent to certain amputations.

38 CFR 3.310(b) provides that ``ischemic heart disease or other

cardiovascular diseases'' developing in veterans who have suffered a

service-connected amputation of one lower extremity at or above the

knee, or service-connected amputations of both lower extremities at or

above the ankles, shall be held to be the result of the service-

connected amputation or amputations. Since that issue is addressed

elsewhere in VA's regulations, it is unnecessary to address it here.

Furthermore, as previously discussed, it would be inappropriate to

include material about the determination of service connection in the

rating schedule.

One commenter recommended that we include more discussion of

pertinent clinical and nonclinical factors to be considered in

assigning evaluations within this portion of the rating schedule.

We have made a number of changes along these lines that will assist

in the evaluation of cardiovascular conditions. Most significantly, we

have adopted more objective evaluation criteria based on specific

clinical (and, in some cases, laboratory) findings, e.g., by using the

level of METs (metabolic equivalents, discussed in detail below) to

assess the severity of heart disease. In addition, we have retained or

added notes, as appropriate, containing clinical information, e.g., by

adding a note defining characteristic attacks of Raynaud's syndrome.

One commenter suggested that Sec. 4.100 discuss forms of heart

disorder, Sec. 4.101 discuss hypertension, and Sec. 4.102 discuss

varicose veins.

A regulation is an agency statement of general applicability and

future effect, which the agency intends to have the force and effect of

law, that is designed to implement, interpret, or prescribe law or

policy, or to describe the procedure or practice requirements of an

agency (Executive Order 12866, Regulatory Planning and Review).

Background material, such as general medical information that is

available in standard textbooks, or other material that neither

prescribes VA policy nor establishes procedures a rating activity must

follow, falls outside of those parameters and is, therefore, not

appropriate in a regulation. The material about the age of onset,

course, etc., of rheumatic fever in former Sec. 4.101 is general

medical information which has no bearing on evaluating the condition,

and we have deleted this material as not appropriate in a regulation.

Upon further review, we have deleted the list of heart abnormalities

from proposed Sec. 4.100 because it too is general medical information

that we do not intend to have the force and effect of law.

We proposed to retitle Sec. 4.101 ``Hypertension,'' and to revise

the content to include a prohibition against separately evaluating

hypertension that is secondary to thyroid or renal disease; and a

requirement that, in a veteran with service-connected hypertension,

arteriosclerotic manifestations are to be service-connected. One

commenter suggested adding more information to Sec. 4.101 about

secondary hypertension, to include specifying when secondary

hypertension can be evaluated separately from the condition causing it.

The rule regarding evaluation of hypertension secondary to renal

disease is included in the part of the rating schedule addressing the

genitourinary system at Sec. 4.115; secondary hypertension associated

with aortic insufficiency or thyroid disease, and isolated systolic

hypertension, which may be secondary to arteriosclerosis, are addressed

under DC 7101 (hypertensive vascular disease). Since the issue of

service connection of secondary hypertension is addressed in more

appropriate areas of the regulations, it should not be addressed here,

and rather than expanding this material, we have deleted it from

Sec. 4.101.

The material in proposed Sec. 4.101 about conditions that are

complications of hypertension or other medical conditions is also

general medical information available in standard texts. As discussed

above, it is not appropriate in a regulation, and we have, therefore,

removed it. The issue of service connection for conditions that are

proximately due to or the result of a service-connected condition is

addressed at 38 CFR 3.310(a). It is, therefore, unnecessary to address

the issue in Sec. 4.101, and we have removed that material also.

In the former schedule, Sec. 4.102, which was titled ``Varicose

veins and phlebitis,'' discussed the necessity of testing for

impairment of deep circulation in varicose veins. We proposed to

retitle it ``Varicose veins'' but to retain the material about deep

circulation. Under the revised evaluation criteria for varicose veins

adopted in this rule, however, determining whether the deep circulation

is impaired is unnecessary because the evaluation criteria focus on

functional impairment rather than the location of the venous

insufficiency. We have, therefore, deleted that material from

Sec. 4.102.

Another commenter requested that we address in Sec. 4.101 the

advances in medical science or objective foundation for requiring that

adjudicators attempt to apportion cardiac signs and symptoms that are

attributable to nonservice-connected arteriosclerotic heart disease

that is superimposed on service-connected rheumatic heart disease.

While it is often possible through modern technology to determine

the separate effects of coexisting heart diseases, such a determination

requires a medical assessment on a case-by-case basis and cannot be

determined by regulation. We have, therefore, revised the material to

require that the rating agency request a medical opinion when it is

necessary to determine whether

[[Page 65210]]

current signs and symptoms can be attributed to one of the coexisting

conditions. Since the material is not relevant to the entire

cardiovascular portion of the rating schedule, we have moved it to a

note under DC 7005, arteriosclerotic heart disease.

One commenter suggested adding a section to explain which

diagnostic codes should not be combined in the case of coexisting

cardiovascular diseases.

As in the case of coexisting heart diseases, determining whether

coexisting cardiovascular diseases have functional impairments that can

be separately evaluated must be determined on a case-by-case basis,

depending on the particular manifestations of each condition. We,

therefore, make no change based on this suggestion.

One commenter recommended that we include cor pulmonale in the

cardiovascular portion of the schedule.

Cor pulmonale is a combination of hypertrophy and dilatation of the

right ventricle secondary to pulmonary hypertension, which is due to

disease of the lung parenchyma or pulmonary vascular system (Braunwald,

1581). Since cor pulmonale is always secondary to a lung condition, and

since it is included in the evaluation criteria for various conditions

of the respiratory system, in our judgment it is not appropriate to

include it in the cardiovascular portion of the rating schedule. For

the sake of clarity, however, we have placed a note in Sec. 4.104

before DC 7000 instructing rating agencies to evaluate cor pulmonale as

part of the pulmonary condition that causes it.

The previous rating schedule provided a 100-percent evaluation for

rheumatic heart disease (DC 7000) ``as active disease and, with

ascertainable cardiac manifestation, for a period of six months.'' We

proposed to retitle DC 7000 ``valvular heart disease,'' and to provide

a 100-percent evaluation for ``active infections with valvular heart

damage for three months following cessation of therapy.''

Three commenters objected to the proposed change in the length of

the convalescence evaluation for DC 7000 (valvular heart disease).

Rheumatic fever is the condition most commonly associated with

valvular heart damage, and its acute phase rarely lasts longer than

three months (Braunwald, 1729). The level of activity following this

period depends on the severity of residual disease (Cecil, 1637). While

in the past patients with acute rheumatic fever were put to bed for

several months, bed rest is no longer considered necessary unless there

is significant carditis (Hurst, 1527). In addition, most rebounds of

rheumatic fever (that is, reappearances of clinical or laboratory

evidence of acute rheumatic fever following cessation of treatment)

occur within two weeks after cessation of therapy, and do not occur

more than five weeks after complete cessation of anti-rheumatic therapy

(Braunwald, 1730). In our judgment, three months following cessation of

therapy is a reasonable period to allow for stabilization of valvular

damage due to infection, and we have retained the convalescence

provision as proposed, except for minor editorial changes.

We proposed that valvular heart disease (DC 7000) be evaluated on

the basis of the level of physical activity, i.e., ``any,'',

``ordinary,'' or ``strenuous,'' required to produce cardiac symptoms,

such as ``dyspnea,'' ``fatigue,'' etc. We received three comments

objecting to the proposed criteria.

One commenter suggested that although the proposed general rating

formula for rheumatic heart disease (DC 7000), arteriosclerotic heart

disease (DC 7005), and ventricular arrhythmia (DC 7011) is consistent

with the classifications of the New York Heart Association, they are

mostly for subjective complaints, and the commenter suggested that the

current criteria be retained except for deleting words like

``characteristic'' and ``definitely.'' Another commenter stated that

the proposed criteria for valvular heart disease are highly subjective

and urged that we adopt objectively confirmable criteria at every

level.

We agree that more objective criteria would result in more

consistent evaluations. In our judgment, however, simply removing such

terms as ``characteristic'' and ``definitely'' from the criteria in the

previous schedule would not have the intended effect. We have,

therefore, revised the criteria to incorporate objective measurements

of the level of physical activity, expressed in METs (metabolic

equivalents), at which cardiac symptoms develop. This does not

represent a substantive change in the method of evaluating cardiac

disabilities that we proposed, i.e., basing evaluations on the level of

physical activity that causes symptoms, but is an objective method for

measuring the level of activity that causes symptoms.

The exercise capacity of skeletal muscle depends on the ability of

the cardiovascular system to deliver oxygen to the muscle, and

measuring exercise capacity can, therefore, also measure cardiovascular

function. The most accurate measure of exercise capacity is the maximal

oxygen uptake, which is the amount of oxygen, in liters per minute,

transported from the lungs and used by skeletal muscle at peak effort

(Braunwald, 1382). Because measurement of the maximal oxygen uptake is

impractical, multiples of resting oxygen consumption (or METs) are used

to calculate the energy cost of physical activity. One MET is the

energy cost of standing quietly at rest and represents an oxygen uptake

of 3.5 milliliters per kilogram of body weight per minute. The

calculation of work activities in multiples of METs is a useful

measurement for assessing disability and standardizing the reporting of

exercise workloads when different exercise protocols are used

(Braunwald, 162).

We have revised the evaluation criteria for the major types of

heart disease based on: the level of physical activity, expressed in

METs, that leads to cardiac symptoms; whether there is heart failure;

the extent of any left ventricular dysfunction; the presence of cardiac

hypertrophy or dilatation; and the need for continuous medication. We

had proposed that valvular heart disease (DC 7000) be evaluated on the

basis of the level of physical activity that produces symptoms--100

percent if ``any,'' 60 percent if ``ordinary,'' and 30 percent if

``strenuous'' activity produces symptoms. We have revised those

criteria to assign a 100-percent evaluation if a workload of three METs

or less produces dyspnea, fatigue, angina, dizziness, or syncope. A

workload of three METs represents such activities as level walking,

driving, and very light calisthenics. We have revised the criteria to

assign a 60-percent evaluation if a workload of greater than three METs

but not greater than five METs results in cardiac symptoms. Activities

that fall into this range include walking two and a half miles per

hour, social dancing, light carpentry, etc. We have revised the

criteria to assign a 30-percent evaluation if a workload of greater

than five METs but not greater than seven METs produces symptoms.

Activities that fall into this range include slow stair climbing,

gardening, shoveling light earth, skating, bicycling at a speed of nine

to ten miles per hour, carpentry, and swimming (Fox, S. M. III,

Naughton, J.P., Haskell, W.L.: Physical activity and the prevention of

coronary heart disease. Ann. Clin. Res., 3:404, 1971 and Goldman, L. et

al.: Comparative reproducibility and validity of systems for assessing

cardiovascular functional class: Advantages of a new specific activity

[[Page 65211]]

scale. Circulation 64:1227, 1981). METs are measured by means of a

treadmill exercise test, which is the most widely used test for

diagnosing coronary artery disease and for assessing the ability of the

coronary circulation to deliver oxygen according to the metabolic needs

of the myocardium (Cecil, 175 and Harrison, 966).

Administering a treadmill exercise test may not be feasible in some

instances, however, because of a medical contraindication, such as

unstable angina with pain at rest, advanced atrioventricular block, or

uncontrolled hypertension. We have, therefore, provided objective

alternative evaluation criteria, such as cardiac hypertrophy or

dilatation, decreased left ventricular ejection fraction, and

congestive heart failure, for use in those cases. We have also

indicated that when a treadmill test cannot be done for medical

reasons, the examiner's estimation of the level of activity, expressed

in METs and supported by examples of specific activities, such as slow

stair climbing or shoveling snow that results in dyspnea, fatigue,

angina, dizziness, or syncope, is acceptable.

The other objective criteria that we have added as alternatives to

the METs-based criteria for valvular heart disease are a left

ventricular ejection fraction of less than 30 percent or chronic

congestive heart failure for a 100-percent evaluation; a left

ventricular ejection fraction of 30 to 50 percent, or more than one

episode of acute congestive heart failure in the past year for a 60-

percent evaluation; evidence of cardiac hypertrophy or dilatation on

electrocardiogram, echocardiogram, or X-ray for a 30-percent

evaluation, and a requirement for continuous medication for a 10-

percent evaluation.

Since neurologic, gastrointestinal, and other cardiovascular

disorders may result in symptoms similar to those for valvular heart

disease, we have also added a requirement that valvular heart disease

be documented by findings on physical examination and by

echocardiogram, Doppler echocardiogram, or cardiac catheterization.

Another commenter felt that the proposed criteria for the 100-

percent level for valvular heart disease (DC 7000), arteriosclerotic

heart disease (DC 7005), and ventricular arrhythmias (DC 7011)--that

``any'' physical activity results in specified cardiac symptoms--

correlates not with total industrial impairment but with being

housebound or helpless. Similarly, the commenter objected that the

requirement for the 60-percent level--that ``ordinary'' physical

activity results in symptoms--actually represents total impairment.

The proposed criteria for the 100-percent level of these conditions

were meant to indicate a severe level of impairment, but the language

was imprecise and perhaps suggested a degree of impairment beyond total

impairment. Under the more objective criteria that we are adopting

here, a 100-percent evaluation requires that a workload of three METs

or less produces dyspnea, fatigue, angina, dizziness, or syncope. A

workload of three METs includes such activities as level walking,

driving, and very light calisthenics. While the development of cardiac

symptoms at this level of activities indicates total impairment, it

does not suggest that the patient is either housebound or helpless.

Similarly, under the more objective criteria, a 60-percent evaluation

requires that a workload of greater than three METs but not greater

than five METs produces cardiac symptoms. Since activities that fall

into this range include walking two and a half miles per hour, social

dancing, and light carpentry, this range does not represent total

impairment. In our judgment, by adopting more objective criteria, we

have eliminated the problem that the commenter identified.

The prior schedule assigned a 10-percent evaluation under DC 7000

(rheumatic heart disease, now designated as valvular heart disease),

when there was an identifiable valvular lesion, with little dyspnea and

no cardiomegaly. We proposed to delete the 10-percent level and to

evaluate the condition as zero percent disabling if it does not limit

physical activity.

Two commenters objected to the proposed deletion of a 10-percent

level of evaluation for valvular heart disease. One suggested a 10-

percent evaluation when dietary adjustments and medication are

necessary to control symptoms or prevent emboli; the other suggested a

10-percent evaluation for asymptomatic valvular heart disease or

arrhythmias that require medication.

Upon further consideration, we have added a 10-percent evaluation,

which will be assigned when symptoms develop at a workload of greater

than 7 METs but not greater than 10 METs. Activities that fall into

this range include jogging, playing basketball, digging ditches, and

sawing hardwood. When symptoms develop only during such activities,

there may be some impairment of earning capacity, but it is likely to

be slight. We have also established an alternative criterion for a 10-

percent evaluation--the need for continuous medication--consistent with

the 10-percent evaluations assigned under other body systems, e.g.,

gynecological and endocrine conditions, when continuous medication is

required. We have also deleted the zero-percent level of evaluation as

unnecessary, since zero percent may be assigned under any diagnostic

code when the criteria for a compensable evaluation are not met (38 CFR

4.31).

DC 7000 was titled ``rheumatic heart disease'' in the previous

schedule. We proposed to retitle it ``valvular heart disease,'' and to

specify that it included rheumatic heart disease, syphilitic heart

disease, and sequelae involving valvular heart damage from

endocarditis, pericarditis, or trauma. Because each of the conditions

listed under DC 7000 (except trauma) has its own diagnostic code and

criteria, we have revised the title to ``valvular heart disease

(including rheumatic heart disease)'' and deleted the list of

conditions. The term ``valvular heart disease'' encompasses all types

of valvular disease not otherwise specified, including those due to

trauma.

We proposed to require that endocarditis (DC 7001), pericarditis

(DC 7002), and pericardial adhesions (DC 7003) be rated as valvular

heart disease. We have instead repeated the evaluation criteria under

each diagnostic code to which they apply. We have also deleted the

three-month period of convalescence evaluation that would have been

available for pericardial adhesions if evaluated strictly under the

criteria for valvular heart disease (DC 7000); pericardial adhesions

are a chronic condition rather than an acute infection, and a

convalescence evaluation is, therefore, inappropriate.

We proposed that syphilitic heart disease (DC 7004) be evaluated

under the criteria for either valvular heart disease or aortic aneurysm

(DC 7110). We have now provided criteria for DC 7004 that are based on

the same objective measurements of the level of physical activity that

causes symptoms. We placed a note following this diagnostic code

directing that syphilitic aortic aneurysms be evaluated under DC 7110

(aortic aneurysm), since the criteria under DC 7110 apply to aortic

aneurysm of any etiology. Since syphilitic heart disease has no phase

of active infection, being the late result of a much earlier syphilitic

infection, we have omitted the criteria based on active infection, as

we did under DC 7003.

We proposed to revise the length of convalescence evaluation

following a myocardial infarction (DC 7005 or 7006) from six months to

three months. One commenter objected that three months represents the

optimal, rather than the

[[Page 65212]]

average, recovery period following myocardial infarction.

The interval between an uncomplicated myocardial infarction and

return to work is 70-90 days (Braunwald, 1390), and a return to work

evaluation can be performed within five weeks after an uncomplicated

myocardial infarction (``The Heart'' 1115 (J. Willis Hurst, M.D. et al.

eds., 7th ed. 1990)). Complete healing of the myocardium, i.e.,

replacement of the infarcted area by scar tissue, takes six to eight

weeks, and most patients will be able to return to work by 12 weeks,

many much earlier (``Harrison's Principles of Internal Medicine'' 956-

57 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)). This information

clearly establishes that most patients with myocardial infarction

recover within three months, and, in our judgment, that is an adequate

period for a convalescence evaluation.

Another individual said that three months is not an adequate length

of convalescence evaluation following myocardial infarction because it

takes six months, which according to the commenter is the normally

accepted recovery time, for ancillary circulation patterns to develop.

The development of collateral circulation represents a long-range

adaptation to ischemia due to coronary artery disease (Hurst, 944). It

is, therefore, more relevant in predicting whether an infarction will

occur or how severe it might be, than in determining the length of

convalescence after infarction, and we have made no change based on

this comment.

In response to requests for more objective criteria, we have

adopted criteria for the 10-, 30-, 60-, and 100-percent levels for

arteriosclerotic heart disease using the same METs-based criteria we

have adopted for DC 7000 (valvular heart disease). We have also adopted

similar alternative criteria based either on chronic or multiple

episodes of congestive heart failure, left ventricular dysfunction with

decreased ejection fraction percentages, or cardiac hypertrophy or

dilatation.

The prior rating schedule assigned 30-percent evaluations under DCs

7005 (arteriosclerotic heart disease) and 7006 (myocardium, infarction

of, due to thrombosis or embolism) ``following typical coronary

occlusion or thrombosis,'' or ``with history of substantiated anginal

attack, ordinary manual labor feasible,'' but provided neither a 10-

percent level nor specific criteria for a zero-percent evaluation. We

proposed to assign a 30-percent evaluation for those with cardiac

symptoms appearing after strenuous physical activity, and to establish

a zero-percent level for those with no limitation of physical activity.

Two commenters objected to the proposed changes. One suggested we

provide a 20-percent level under DC 7005 for some limitation of

activities and a 30-percent level for one or more symptoms. One felt

that 30 percent should be the minimum under DC 7005 or DC 7006 because

permanent disability results.

In keeping with the objective evaluation criteria we are adopting,

it is feasible to establish additional levels of impairment based on an

objective measurement of the workload at which symptoms develop. We

have added a 10-percent evaluation under DC's 7005 and 7006 for those

who have cardiac symptoms at a workload greater than 7 METs but not

greater than 10 METs, which includes such activities as gardening and

skating. The 10-percent evaluation may also be assigned when continuous

medication is required, which is consistent with the evaluation of

other heart conditions. As a result, if, for different conditions, the

same workload elicits symptoms, the conditions will be assigned the

same evaluation. A 30-percent minimum evaluation is not warranted.

Arteriosclerotic heart disease may be mild enough that it imposes

little or no functional impairment, and, in our judgment, the most

equitable way to evaluate the condition is to do so objectively

according to the physical workload that causes symptoms.

We proposed that arteriosclerotic heart disease (DC 7005) and

myocardial infarction (DC 7006) be evaluated under the same criteria.

That was reasonable under the subjective evaluation criteria that were

proposed, but there are some condition-specific differences that the

criteria must reflect. We have provided for a three-month convalescence

evaluation following a myocardial infarction (DC 7006), a condition of

sudden onset. Arteriosclerotic heart disease (DC 7005), on the other

hand, is a chronic condition that does not warrant a convalescence

evaluation. We have added a requirement to DC 7005 that the veteran

have ``documented'' coronary artery disease. Similarly, we have headed

DC 7006 with the statement ``with history of myocardial infarction,

documented by laboratory tests.'' This replaces the requirement that

the myocardial infarction be ``typical'' in order to assign the

convalescence evaluation. Since atypical myocardial infarctions may be

just as disabling as typical ones, we have revised the criteria for a

convalescence rating to require that an infarction be ``documented''

rather than ``typical.''

We have deleted the instruction proposed under DC 7005 that

cardiomyopathies (DC 7020) and hypertensive heart disease (DC 7007) are

to be rated as arteriosclerotic heart disease because we have provided

each of these conditions with criteria under its own diagnostic code.

We proposed that hypertensive heart disease (DC 7007) be evaluated

under the criteria for arteriosclerotic heart disease, i.e., percentage

evaluations based on the level of activity that causes symptoms, and we

have revised the criteria using the same objective evaluation criteria

as for arteriosclerotic heart disease.

We have made minor editorial changes under DC 7008 (hyperthyroid

heart disease).

We proposed that a 30-percent evaluation under DC 7010

(supraventricular arrhythmias) require paroxysmal atrial fibrillation

or other supraventricular tachycardia, with severe frequent attacks

despite therapy, and that the 10-percent evaluation require permanent

atrial fibrillation or infrequent or mild attacks documented by

electrocardiogram (ECG) or Holter monitor.

Two commenters pointed out that such phrases as ``severe, frequent

attacks'' are indefinite, and one suggested that we replace these terms

with more objective ones.

We agree and have revised the criteria to require more than four

episodes a year of paroxysmal atrial fibrillation or other

supraventricular tachycardia for the 30-percent level, and permanent

atrial fibrillation or one to four episodes a year of paroxysmal atrial

fibrillation or other supraventricular tachycardia for the 10-percent

level. Both sets of criteria require documentation by ECG or Holter

monitor.

We proposed to evaluate sustained ventricular arrhythmias (DC 7011)

according to whether ``ordinary'' or ``strenuous'' activity results in

palpitations or symptoms of arrhythmia. A commenter objected to the

subjectivity of the proposed criteria for DC 7011.

Based on this comment, we have revised the criteria using the same

objective measurements that we are using for arteriosclerotic heart

disease. We have, however, retained specific provisions for a total

evaluation while an Automatic Implantable Cardioverter-Defibrillator

(AICD) is in place. The use of AICDs is associated with the potential

for serious complications such as myocardial infarction, stroke,

cardiogenic shock, and complications

[[Page 65213]]

associated with the thoracotomy required for its insertion (Braunwald,

750). We have revised the language slightly to make it clear that a

100-percent evaluation will be assigned for as long as the AICD is in

place. We have also made other nonsubstantive changes in the language

at 100 percent for the sake of clarity.

The previous schedule provided a 100-percent evaluation for DC

7015, atrioventricular block, for one year following implantation of a

pacemaker when required by a complete heart block with attacks of

syncope, and a 60-percent evaluation for complete heart block with

Stokes-Adams attacks several times a year despite medication or a

pacemaker. We proposed to eliminate the 100-percent level while

retaining essentially the same criteria for the other levels.

One commenter stated that a 100-percent evaluation is warranted

under DC 7015 when there is a complete heart block with syncopal

attacks despite therapy or a pacemaker. Another commenter suggested

that we replace the requirement for ``several'' attacks a year for the

60-percent evaluation under DC 7015 with a definite number.

Upon further review, in response both to these comments and to the

requests for more objective criteria, we have revised the criteria for

DC 7015 by providing the same objective evaluation criteria we have

used for ventricular arrhythmias (DC 7011) and many other heart

conditions, since heart block may result in a variety of cardiac signs

and symptoms and a wide range of disabilities. This change restores the

100-percent evaluation level. These criteria replace evaluation

criteria based on the electrocardiographic designation of complete or

incomplete block. Because both complete and incomplete heart blocks can

differ in severity, basing evaluations on the degree of heart block

could lead to different evaluations for similar symptoms. In our

judgment, the revised criteria are a better measure of the disabling

effects of atrioventricular block than whether the block is complete or

incomplete.

The only difference in the criteria for atrioventricular block (DC

7015) and ventricular arrhythmias (DC 7011) is that a 10-percent

evaluation for DC 7015 will be assigned when either a pacemaker, a

common method of treatment for this condition, or continuous medication

is required. We have deleted the proposed zero-percent evaluation,

since under the provisions of 38 CFR 4.31a, a zero-percent evaluation

may be assigned when the findings are less than those needed for a

compensable level. We have also edited the note requiring that certain

unusual cases of associated arrhythmias are to be submitted to the

Director of the Compensation and Pension Service for evaluation, for

the sake of clarity.

The previous schedule established a minimum 30-percent evaluation

for heart valve replacement (DC 7016); we proposed a 30-percent

evaluation when strenuous activity causes specific cardiac symptoms,

and a zero-percent evaluation when the condition imposes no limitation

of physical activity. One commenter suggested that we retain the 30-

percent minimum evaluation, but gave no rationale for the suggestion.

The level of residual disability following valve replacement can

also be objectively determined based on the level of activity that

results in symptoms in the same manner as for valvular heart disease.

We have, therefore, revised the criteria to assign a 30-percent

evaluation when a workload of greater than 5 METs but not greater than

7 METs results in symptoms, or when there is evidence of cardiac

hypertrophy or dilatation. For the sake of consistency with the

evaluation criteria for other heart conditions evaluated based on the

level of physical activity that causes symptoms, we have added a ten-

percent evaluation when a workload of greater than 7 METs but not

greater than 10 METs results in symptoms. In our judgment, specific

symptoms warrant the same evaluation whether they occur before or after

valve replacement, and we are not aware of any special circumstances

following valve replacement that would justify a 30-percent minimum

evaluation.

We have edited the language of the note regarding the assignment of

100 percent following admission for heart valve replacement to assure

that the provisions of Sec. 3.105(e) will be followed whether the

reduction from the 100-percent evaluation is based upon the mandatory

examination six months following discharge or following a subsequent

examination.

The previous schedule called for a total evaluation for one year

following heart valve replacement (DC 7016). We proposed a total

evaluation for an indefinite period, with a mandatory VA examination

six months after the surgery, with any change in evaluation based on

that or any subsequent examination to be made under the provisions of

38 CFR 3.105(e).

One commenter objected to the proposed change, stating that heart

valve replacement is a high risk surgical procedure, and many patients

have post-operative congestive heart failure for a considerable time.

Another commenter said that the proposed reduction in length of the

convalescence evaluation is arbitrary, that it goes beyond the purpose

of the review, and that no justification has been provided.

We recognize that it ordinarily takes patients longer to recover

from valve replacement than from acute valvular infection,

endocarditis, or pericarditis and, therefore, proposed an indefinite

period of total evaluation. We believe that six months following

discharge from the hospital is a reasonable time at which to examine a

patient to determine whether the condition has stabilized and the

extent of residual disability. If the results of that or any subsequent

examination warrant a reduction in evaluation, the reduction will be

implemented under the notice and effective date provisions of 38 CFR

3.105(e), which require a 60-day notice before VA reduces an evaluation

and an additional 60-day notice before the reduced evaluation takes

effect. By requiring an examination, the revised procedure will assure

that all residuals are documented; it also ensures that the veteran

receive timely notice of any proposed action and have an opportunity to

present evidence showing that the proposed action should not be taken.

In our judgment, this method will better ensure that actual residual

disabilities and recuperation times are taken into account because they

will be documented on examination.

We proposed to change the length of the total evaluation following

coronary artery bypass surgery (DC 7017) from one year to three months.

One commenter objected, stating that unspecified medical textbooks

suggest resumption of sedentary activity over the two-to three-month

period following surgery, with resumption of full activity after three

months. Another expressed his belief that a reduction to three months

is unreasonably restrictive and does not reflect the average impairment

for those in poor health or those who have cardiomyopathies or

pulmonary and systemic organ congestion.

An article in the Journal of the American College of Cardiology

(1029 vol. 14, no. 4, Oct. 1989) entitled ``Insurability and

Employability of the Patient with Ischemic Heart Disease'' states that

return to work evaluations are appropriate seven weeks after bypass

surgery. Neither this article nor the unidentified information cited by

the commenter justifies the need for a convalescence evaluation longer

than three months. For the individual who requires a longer than

average period of convalescence, a total evaluation may be assigned for

a longer period under the provisions of Secs. 4.29 and 4.30 of the

[[Page 65214]]

rating schedule. We have, therefore, retained the provision assigning a

total evaluation for three months following surgery as proposed.

We proposed that coronary artery bypass surgery be evaluated using

the evaluation criteria for arteriosclerotic heart disease, which was

not a change from the previous schedule. One commenter suggested that

30 percent be the minimum evaluation following bypass surgery,

analogous to arteriosclerotic heart disease (DC 7005).

We have provided objective criteria for evaluation following

coronary bypass surgery that are the same as the criteria we have

provided for arteriosclerotic heart disease (DC 7005). The surgery

itself does not necessarily produce a 30-percent level of impairment;

in fact, it often alleviates the disability from arteriosclerotic heart

disease. In our judgment, an evaluation based on the workload at which

symptoms develop is a reasonable and consistent way to assess the

extent of disability; a 30-percent evaluation will be assigned if

symptoms develop at the same workload that warrants a 30-percent

evaluation for other cardiac conditions.

One commenter suggested that we add a convalescence evaluation

following balloon angioplasty for coronary artery disease.

Most patients who undergo balloon angioplasty are discharged from

the hospital 24 hours or less after surgery, and many can return to

work in a week or less after a successful and uncomplicated angioplasty

(Hurst, 2145 and Braunwald, 1367). In our judgment, a total evaluation

for a specified period to allow for convalescence is, therefore, not

warranted.

We proposed changing the duration of the total evaluation following

implantation of a cardiac pacemaker (currently Note (2) under DC 7015,

proposed as DC 7018) from one year to two months. One commenter said

that the total evaluation should continue for one year; another said

that pacemakers require close monitoring postoperatively and that

patients should not concern themselves with a return to activity sooner

than medically advisable.

Pacemaker implantation is not major surgery, nor is it associated

with debilitating or long-term residuals. Those who undergo a cardiac

pacemaker implantation are usually discharged from the hospital the

following day and are seen in follow-up two weeks after surgery to

check the wound and to test the pacing system (Hurst, 2103-4). They are

subsequently evaluated two months after implantation, and virtually all

patients will have definitive pacemaker programming for long-term

function at that time (Braunwald, 747). Thereafter, there is periodic

monitoring, often conducted by telephone. In our judgment, a two-month

convalescence evaluation is adequate for a normal recovery from

pacemaker implantation.

One commenter suggested that we add a 100-percent evaluation under

DC 7018, implantable cardiac pacemakers, for those patients who require

frequent follow-up and adjustment after pacemaker implant.

DC 7018 allows evaluation of a patient's condition following

implantation of a pacemaker under supraventricular arrhythmias (DC

7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC

7015), if appropriate. A 100-percent evaluation may, therefore, be

assigned based either on symptoms or on the number of episodes of

arrhythmia, depending on the diagnostic code used. These criteria are a

better indicator of residual disability than the frequency of

adjustments or follow-up, and we have made no change based on this

suggestion.

Another commenter felt that 30 percent should be the minimum

evaluation for DC 7018 after a pacemaker has been implanted.

A pacemaker requires regular checkups and monitoring, often by

telephone, but the patient may, in fact, be asymptomatic. An evaluation

of 10 percent rather than 30 percent is more appropriate for such

cases, and we have added a minimum evaluation of 10 percent to the

criteria under DC 7018. This is comparable to the assignment of 10

percent for other cardiac conditions when continuous medication is

required.

One commenter suggested that we add a caveat under pacemaker

implantation (DC 7018) that reimplantation or replacement of a

pacemaker does not warrant a 100-percent evaluation.

The total evaluation for two months following implantation of a

pacemaker is to provide a period of recuperation from the surgery and

any possible side-effects, as well as to provide a period to adjust the

device itself and test the response of the individual's heart. These

considerations apply as well to the replacement of a pacemaker, and, in

our judgment, limiting convalescence evaluations to the initial

implantation only is not warranted.

We proposed to add a new diagnostic code (DC 7019) for cardiac

transplantation allowing a total evaluation for an indefinite period

following the transplant, with a mandatory VA examination to be

conducted one year later. In the past, with no provision for cardiac

transplantation in the rating schedule, a fixed period of convalescence

evaluation for two years was assigned, analogous to what the rating

schedule provided following renal transplant prior to the revisions to

the genitourinary portion of the rating schedule published January 18,

1994.

One commenter stated that the total evaluation following cardiac

transplantation (DC 7019) should continue for two years because the

risk of rejection and survival data show that this is dangerous

surgery.

Because more than 85 percent of one-year survivors of a cardiac

transplant have been rehabilitated and return to work or to school by

the end of one year after transplant (Hurst, 2253-54), in our judgment,

one year following hospital discharge is a reasonable time to conduct

an examination in order to assess residual disability. As with other

indefinite periods of convalescence evaluation, any change in

evaluation based on the results of the examination will be implemented

under the notice and effective date provisions of Sec. 3.105(e), which

require VA to notify the claimant of any proposed reduction, once the

examination has been carried out and reviewed, and allows 60 days for

the claimant to provide additional evidence to show that a reduction

should not be carried out.

We proposed to evaluate cardiac transplantation (DC 7019) under the

same criteria as arteriosclerotic heart disease (DC 7005), i.e.,

according to the level of activity that causes symptoms; we have,

therefore, revised the criteria using the same objective measurements

that we have adopted for evaluating arteriosclerotic heart disease. We

proposed a minimum 30-percent evaluation following cardiac

transplantation as long as the veteran is on immunosuppressive

medication. Because almost every patient will permanently require

immunosuppressive therapy following cardiac transplantation, we have

simply made 30 percent the minimum evaluation and deleted the

requirement that the veteran be taking immunosuppressive medication.

This is consistent with the minimum evaluation for kidney transplant

(DC 7531), which was published in the Federal Register of January 18,

1994 (59 FR 2523).

We also proposed to evaluate cardiomyopathy (DC 7020) under the

same criteria as arteriosclerotic heart disease (DC 7005), i.e.,

according to the level of activity that causes symptoms;

[[Page 65215]]

we have, therefore, revised the criteria using the same objective

measurements that we have adopted for evaluating arteriosclerotic heart

disease.

The previous schedule had a diagnostic code, DC 7100, for

generalized arteriosclerosis, which we proposed to delete. One

commenter objected, stating that this condition, which is often present

in geriatric cases, produces total industrial incapacity with

involutional changes such as cerebral ischemia with reduced mentation,

bone and muscle atrophy, etc.

The effects of generalized arteriosclerosis are so widespread that,

in our judgment, a single diagnostic code is neither appropriate nor

necessary. Many diagnostic codes, such as DC 7005, arteriosclerotic

heart disease, DC 7114, arteriosclerosis obliterans, and DC 9305,

multi-infarct dementia associated with cerebral arteriosclerosis,

represent potential effects of arteriosclerosis on end organs, and

evaluating each disability resulting from generalized arteriosclerosis

under an appropriate code will result in more accurate assessments of

the actual disabilities caused by the condition. We have, therefore,

made no change based on this comment.

Two commenters requested that we define the term hypertension (DC

7101).

In response to this comment, we have revised Note (1) under DC 7101

to state that, for purposes of this section, hypertension means that

the diastolic blood pressure is predominantly 90mm. or greater, and

that isolated systolic hypertension means that the systolic blood

pressure is predominantly 160mm. or greater with a diastolic blood

pressure of less than 90mm. (Cecil, 253, based on the 1988 report of

the Joint National Committee on Detection, Evaluation, and Treatment of

High Blood Pressure).

Since both essential hypertension and secondary types of

hypertension, such as isolated systolic hypertension due to

arteriosclerosis, may be evaluated under this diagnostic code, we have

revised the title of DC 7101 from Hypertensive vascular disease

(essential arterial hypertension) to Hypertensive vascular disease

(hypertension and isolated systolic hypertension).

In the previous schedule, Note (1) under DC 7101 (hypertensive

vascular disease) stated that the 40- and 60-percent evaluations

required careful attention to diagnosis and repeated blood pressure

readings. We proposed to revise the note to state that careful and

repeated measurements of blood pressure readings are required prior to

the assignment of any compensable evaluation.

Two commenters requested that we clarify the meaning of the note.

Standard medical texts recommend multiple blood pressure readings for

the diagnosis of hypertension, although the number of measurements

recommended varies, with ``at least three sets over at least a three-

month interval'' (Braunwald, 818) and ``at least two measurements on

two separate examinations'' (Harrison, 1001) among the specific

recommendations. We have revised the note to require that hypertension

be confirmed by readings taken two or more times on each of at least

three different days. This will assure that the existence of

hypertension is not conceded based solely on readings taken on a

single, perhaps unrepresentative, day.

In a note under DC 7101 (hypertensive vascular disease), the

previous schedule established a minimum evaluation of ten percent when

medication is necessary to control hypertension with a history of

diastolic blood pressure predominantly 100 or more. We proposed to keep

this note.

One commenter asked if 10 percent should be assigned whenever

continuous medication is required for any disorder; another asked if

the assignment of 10 percent for hypertension should depend on the

amount of medication required.

In our judgment, it would not be appropriate to assign a ten-

percent evaluation for every condition which requires continuous

treatment by medication. Whether a ten-percent evaluation is warranted

when continuous medication is required is based on a case-by-case

assessment of each condition and the usual effects of treatment. As to

the second comment, the evaluation for hypertension is based not on the

amount of medication required to control it, but on the level of

control that can be achieved. While there may be more side effects with

higher levels of medication or with combined antihypertensive

medications, the disabling side effects of medication may be separately

evaluated under the provisions of 38 CFR 3.310(a).

Since the provision concerning the assignment of a minimum ten-

percent evaluation when there is a history of diastolic pressure

predominantly 100 or more and continuous medication is required

represents part of the evaluation criteria, we have included it in the

criteria for a ten-percent evaluation, rather than in a separate note,

as proposed.

The previous schedule called for a 100-percent evaluation for

aortic aneurysm (DC 7110) when there are markedly disabling symptoms

and for one year following surgical correction. Because of a

typographical error, omission of a semicolon, the proposed criteria as

published implied that a total evaluation would be assigned following

surgery only if the aneurysm had been 5 cm. or more in diameter. One

commenter pointed out this error. We had intended to propose that

veterans be evaluated as totally disabled under either of two

circumstances: (1) If the aneurysm is 5 cm. or greater in diameter, or

(2) for six months following resection of an aneurysm of any size. We

have corrected the error in the final rule.

In addition, to assure internal consistency, we have revised the

criteria to allow a 100-percent evaluation under DC 7110 in an

additional situation: when an aortic aneurysm is symptomatic. Under DC

7111, aneurysm of any large artery is evaluated at 100 percent if it is

symptomatic. Since the aorta is the largest artery in the body, it

would be inconsistent and inequitable not to allow the same evaluation

that the schedule provides for symptomatic aneurysms of other large

arteries.

The previous schedule assigned a minimum 20-percent evaluation

following surgical correction of aortic aneurysm (DC 7110). We proposed

to evaluate residuals following surgical correction on actual residual

disability, according to the organ system affected, in lieu of

assigning a minimum evaluation. A commenter recommended that we retain

the 20-percent minimum evaluation following surgery, contending that

after such surgery individuals lead a tenuous and extremely sedentary

existence, often requiring revision of the graft.

There is a wide range of possible complications and residual

disability following surgical correction of an aortic aneurysm,

depending on such factors as the location of the aneurysm, its type

(dissecting or not), etc. Because some would warrant a higher, and some

a lower, evaluation than 20 percent, in our judgment it is preferable

to evaluate the actual residuals rather than provide a minimum

evaluation, and we have made no change based on this comment.

We proposed to eliminate the fixed one-year period of convalescence

evaluation following surgical correction of an aortic aneurysm (DC

7110) in favor of a 100-percent evaluation for an indefinite period

from the date of admission for surgical correction, with a mandatory VA

examination six months following discharge, and with any change in

evaluation subject to the notice and effective date provisions of

[[Page 65216]]

Sec. 3.105(e). One commenter urged that we retain the one-year

convalescence evaluation, but gave no specific reasons. We also

proposed an indefinite total evaluation following repair of an aneurysm

of a large artery (DC 7111) although the previous schedule had provided

no post-surgical total evaluation. One commenter suggested that a one-

year period of convalescence evaluation would be appropriate following

repair of an aneurysm of a large artery because, as after aortic

aneurysm repair, these patients lead a tenuous and sedentary existence

after surgery.

The period of total evaluation following surgery under DCs 7110 and

7111 will continue indefinitely under the revised schedule, and an

examination six months following the date of admission for surgical

correction will determine whether a change in evaluation is warranted,

based on actual residuals documented at that time. Since any change

will be implemented under the notice and effective date provisions of

Sec. 3.105 (e), the veteran will have the opportunity to present

medical evidence if he or she disagrees with the proposed change in

evaluation. These provisions assure an evaluation that reflects the

actual disability as documented by medical examination, and we have

made no change based on these comments.

The previous schedule assigned a 10-percent evaluation for aneurysm

of any small artery (DC 7112); we proposed that such an aneurysm be

assigned a zero-percent evaluation. One commenter stated that the

proposed change is based on empirical, as opposed to statistical,

evidence and that evaluations that have stood the test of time should

not be routinely reduced or discontinued.

Small artery aneurysms may produce symptoms such as headaches or

visual abnormalities due to local pressure effects, and an aneurysm

that ruptures may result in a wide variety of symptoms. However, small

artery aneurysms that are asymptomatic are found in about five percent

of the population (Cecil, 2165). Because of the wide range of possible

disabling effects, it is appropriate to rate each one on the actual

findings rather than provide a 10-percent evaluation in all cases. In

our judgment, an asymptomatic aneurysm of a small artery has no

disabling effects and does not warrant a compensable evaluation.

Another commenter asked where and how to rate cerebral aneurysms.

Aneurysms of cerebral arteries are evaluated under DC 7112, as are all

other aneurysms of small arteries. We have made no change in response

to this comment.

The previous schedule specified a minimum evaluation of 60 percent

for traumatic arteriovenous aneurysm (DC 7113) when there is cardiac

involvement, and we proposed no change. One commenter, noting that

designating a minimum evaluation implied that a higher one could be

assigned, asked what findings would warrant an evaluation higher than

60 percent, since 60 percent was also the highest evaluation under DC

7113.

The most serious potential consequence of arteriovenous aneurysm is

congestive heart failure due to high output, which would warrant a 100-

percent evaluation. We have, therefore, added a 100-percent evaluation,

to be assigned if there is high output heart failure.

In response to the request for more objective criteria, we have

revised the criteria for a 60-percent evaluation under DC 7113 to

require an enlarged heart, wide pulse pressure, and tachycardia rather

than the ambiguous term ``cardiac involvement'' that we had proposed.

We have revised the criteria for the 50-percent level for lower

extremity involvement or the 40-percent level for upper extremity

involvement, which were proposed as ``without cardiac involvement with

marked vascular symptoms,'' to require edema, stasis dermatitis, and

either ulceration or cellulitis. We have revised the criteria for the

30-percent level for lower extremity involvement or the 20-percent

level for upper extremity involvement, which were proposed as ``with

definite vascular symptoms,'' to require edema or stasis dermatitis.

These are not substantive changes, but more specific designations of

the cardiac and vascular signs that warrant these evaluations. We have

also revised the title of DC 7113 from ``arteriovenous aneurysm,

traumatic'' to ``arteriovenous fistula, traumatic,'' the currently

accepted term for the condition, which is a direct communication

between an artery and a vein.

One commenter requested that we add a paragraph under

arteriosclerosis obliterans (DC 7114) addressing the evaluation of

aorto-femoral bypass grafts.

To assure consistent evaluations of the residuals of aortic and

large arterial bypass surgery, we have added a note under DC 7114

stating that the residuals of aortic and large arterial bypass surgery

or arterial grafts are to be rated under that code. Since the most

common residuals of bypass surgery are signs and symptoms of arterial

insufficiency, it is appropriate to evaluate them under the criteria

for arteriosclerosis obliterans.

Two commenters suggested we provide a specific period of

convalescence evaluation following bypass surgery for aortoiliac and

femoral-popliteal artery disease.

The evaluation criteria for serious complications that might result

from bypass surgery and, therefore, be service-connected under the

provisions of 38 CFR 3.310(a), such as myocardial infarction, have

their own periods of convalescence evaluation. For the milder

complications, or the uncomplicated cases, the standard periods of

convalescence evaluation authorized under Sec. 4.30 of this part are

adequate, and we have made no change based on these comments.

The criterion for the 40-percent evaluation for arteriosclerosis

obliterans (DC 7114) in the previous schedule was ``well-established

cases with intermittent claudication or recurrent episodes of

superficial phlebitis;'' we proposed to revise this criterion to

``well-established cases of intermittent claudication with associated

physical findings (hair loss, skin changes).'' We proposed for the 100-

percent level: ``severe, with marked physical signs producing total

incapacity''; for the 60-percent level: ``claudication on minimal

walking (less than three miles per hour on a level grade) with

persistent coldness of the extremity''; and for the 20-percent level:

``minimal circulatory impairment, with paresthesias, temperature

changes and occasional claudication.'' One commenter noted that the

phrase ``well-established cases'' is one of the vague, indefinite, and

arbitrary elements in the schedule.

In response to both that comment and the requests for more

objective criteria, we have revised the criteria under this diagnostic

code: To specify at each evaluation level the distance that can be

covered before claudication occurs; and to base evaluations on

objective physical findings, such as peripheral pulses, trophic

changes, persistent coldness, and deep ischemic ulcers. We have also

added an objective alternative criterion, the ankle/brachial index, at

each level, and a note explaining that this index is obtained by

dividing the systolic blood pressure at the ankle by the systolic blood

pressure in the arm. The ratio is normally one or greater; but because

arterial occlusive disease obstructs the blood flow in the legs, the

ratio in patients with that condition is less than one. A ratio of less

than 0.5 is consistent with severe ischemia (Harrison, 1019). The

ankle/brachial index thus allows a noninvasive

[[Page 65217]]

objective assessment of the severity of peripheral vascular disease.

We proposed to evaluate Raynaud's syndrome (DC 7117) as 100-

percent, 60-percent, 40-percent, or 20-percent disabling, using

measures such as ``marked'' circulatory changes, ``multiple'' ulcerated

areas, ``frequent'' vasomotor disturbances, and ``occasional'' attacks

of blanching or flushing. One commenter suggested that we replace

subjective terms with more objective requirements.

Simply replacing the indefinite words would not result in truly

objective criteria. We have, therefore, defined ``characteristic

attacks'' of Raynaud's disease for VA purposes as consisting of

sequential color changes of the digits lasting minutes to hours,

sometimes with pain and paresthesias, and precipitated by exposure to

cold or by emotional upsets. We have revised the evaluation criteria

based on the frequency of characteristic attacks, the number of digital

ulcers, and whether autoamputation in one or more digits has occurred.

While we proposed no change in the former 20-percent level, which

required ``occasional attacks of blanching or flushing,'' under the

more objective criteria we have provided both a 20- and a 10-percent

level, with 20-percent requiring characteristic attacks four to six

times a week, and 10-percent requiring characteristic attacks one to

three times a week. This will ensure more consistent evaluations in

milder cases of Raynaud's, where, in the former schedule, the

assignment of zero percent or 20 percent depended on an individual

rater's interpretation of ``occasional.''

One commenter suggested that we include neurologic symptoms

associated with exposure to low or subfreezing temperatures under the

evaluation criteria for DC 7117.

In response to this comment, we have included pain and

paresthesias, which are neurologic symptoms, among the possible

manifestations of the characteristic attacks of Raynaud's syndrome.

We proposed to assign 40-percent, 20-percent, and zero-percent

evaluations for angioneurotic edema (DC 7118), based generally on the

frequency, severity, and duration of attacks. One commenter recommended

that we add a 10-percent evaluation; another recommended that we

replace language such as ``frequent'' and ``infrequent'' with more

definite terms.

Angioneurotic edema is a condition that is ordinarily self-limited,

with attacks subsiding in one to seven days (Merck, 333), but at times

palliative treatment is used. There are also unusual types that are

more persistent and resistant to therapy. We have established more

objective criteria based on the typical duration of attacks, their

frequency, and on whether there is laryngeal involvement. We have added

a 10-percent evaluation, to be assigned if attacks without laryngeal

involvement occur two to four times a year. These criteria will foster

more consistent evaluations for angioneurotic edema, since different

raters will not be required to interpret subjective terms such as

``mild,'' ``moderate,'' ``frequent,'' and ``infrequent.''

One commenter suggested that when angioneurotic edema affects the

larynx even briefly, a 10-percent evaluation is warranted.

In our judgment, angioneurotic edema affecting the larynx does

warrant separate consideration in the evaluation criteria because

laryngeal edema commonly causes respiratory distress due to airway

obstruction and requires emergency treatment. This situation is serious

enough that if it occurs once or twice a year, it warrants a 20-percent

evaluation; if it occurs more than twice a year, it warrants a 40-

percent evaluation.

A second commenter objected that the proposed changes to DC 7118

were based on empirical, as opposed to statistical, information.

As noted under the response to comments about DC 7122, 38 U.S.C.

1155 gives the Secretary the authority to revise the rating schedule

periodically in accordance with experience. The revisions of these

criteria are based on the usual effects of the disease, which is

consistent with the basis of revisions throughout the current

comprehensive revision of the rating schedule. They are medically,

rather than statistically, based, and no statistical studies were done

in conjunction with the revision.

Under the previous schedule, there were a variety of methods used

to evaluate vascular diseases affecting the extremities, particularly

when more than one extremity was affected. For example, the criteria

for thrombophlebitis (DC 7121) applied to a single extremity, and if

other extremities were affected, they were separately evaluated. For

varicose veins (DC 7120), the criteria for a 10-percent evaluation

applied to either unilateral or bilateral involvement; but at other

evaluation levels, different percentages were assigned for unilateral

and bilateral involvement, with no direction for evaluation if one

extremity were more severely affected than the other. The criteria for

intermittent claudication (DC 7116) applied to a single extremity;

determining the evaluation for multiple extremities required

application of a complex set of rules (contained in a note following DC

7117) that sometimes produced an evaluation for involvement of multiple

extremities no higher than that for involvement of a single extremity.

We proposed no substantive change in either the methods of evaluating

these conditions or in the percentage levels.

One commenter questioned why the percentage evaluations and the

method of determining the evaluation when more than one extremity is

affected differ for arterial and venous diseases. He suggested that we

use 20-, 40,-and 60-percent levels for both peripheral arterial

diseases (DCs 7114 through 7117), and venous diseases (DCs 7120 and

7121) instead of the variety of levels proposed, and that we adopt a

uniform and simple method of determining evaluations when more than one

extremity is involved, such as adding ten percent for each additional

extremity involved.

We proposed evaluations levels of 20, 40, 60, and 100 percent for

DCs 7114, 7115, and 7117, and we have kept those levels in this rule,

with the addition of a 10-percent level for DC 7117. (We removed DC

7116, ``intermittent claudication,'' which was in the previous

schedule, because it was a symptom of disease rather than a disease.)

In response to the comment, we have further revised DCs 7120 (varicose

veins) and 7121 (post-phlebitic syndrome of any etiology) to provide

percentage evaluation levels of 10, 20, 40, 60, and 100 percent. In

addition, we have revised the method of evaluating DCs 7114

(arteriosclerosis obliterans), 7115 (thromboangiitis obliterans), and

7120 (varicose veins) so that the criteria apply to a single extremity,

as the criteria for DC 7121 do. If the paired extremity is also

affected, the evaluation for each extremity will be separately

determined and combined using the combined ratings table (see 38 CFR

4.25) and the bilateral factor (see 38 CFR 4.26) when applicable.

Section 4.26 also provides instructions on applying the bilateral

factor when there is involvement of upper and lower extremities. While

we have made the percentage levels similar, the signs, symptoms, and

effects of venous and arterial diseases differ greatly and, therefore,

require different evaluation criteria.

In order to adopt the more consistent method of separately

evaluating each extremity affected by vascular disease and to assure

that venous conditions with similar findings receive consistent

evaluations, further revisions of the evaluation criteria for varicose

veins

[[Page 65218]]

(DC 7120) and post-phlebitic syndrome of any etiology (DC 7121) were

required.

Varicose veins are ordinarily asymptomatic or mildly symptomatic,

but may produce prolonged venous insufficiency and progress to

thrombophlebitis and postphlebitic syndrome. Signs of venous

insufficiency, such as edema, stasis pigmentation, ulceration, eczema,

and induration, and symptoms such as aching and fatigue, are the major

disabling effects of varicose veins. The size, location, extent, etc.,

of varicose veins do not correlate with symptoms (Merck, 590), and we

have removed those criteria as factors in evaluation. The presence or

absence of impairment of the deep circulation is more an indicator of

the feasibility of surgical repair than of functional impairment, and

we have, therefore, removed references to the deep circulation from the

evaluation criteria. We have replaced these criteria with criteria

based on symptoms (such as aching and fatigue after prolonged standing

or walking) or objective physical findings (such as edema, stasis

pigmentation, eczema, or ulceration).

The effects of chronic venous insufficiency are the same, whether

from varicosities, thrombophlebitis, or some other cause. The

postphlebitic syndrome may itself lead to the development of

varicosities because of chronic venous insufficiency (Cecil, 363-7).

Therefore, the possible manifestations and disabling effects of

varicose veins and postphlebitic syndrome are very similar, and we have

used the same criteria to evaluate both conditions, with evaluation

levels of 0, 10, 20, 40, 60, and 100 percent for involvement of a

single extremity, and the same method of evaluation for multiple

extremity involvement as that used in arterial vascular disease of the

extremities.

We added under DC 7120: ``With the following findings attributed to

the effects of varicose veins,'' and under DC 7121: ``With the

following findings attributed to venous disease'' in order to assure

that the examiner has determined that the abnormal findings are

attributed to venous disease.

One commenter suggested that we clarify how to assign bilateral

evaluations for frozen feet (DC 7122) and varicose veins (DC 7120) when

one extremity is more severely affected than the other.

The changes described above that we have made in the evaluation

criteria, evaluation percentages, and method of determining an

evaluation for multiple extremity involvement will allow accurate and

consistent evaluations when more than one extremity is affected by

varicose veins, but to different degrees. We have made similar changes

in the method of evaluating cold injury, DC 7122, in order to assure

accurate and consistent evaluations when there is multiple extremity

involvement, and this is further discussed below.

We proposed no change in the previous evaluation criteria for

frozen feet (DC 7122). One commenter suggested that we expand the

criteria to include cold injuries to the hands, face, and ears; another

suggested that higher ratings may be warranted for loss of use of

multiple fingers or one or both hands.

We have revised the title of DC 7122 from ``frozen feet, residuals

of'' to ``cold injury, residuals of'' to indicate that it may be used

to evaluate any cold injury. Because cold injury produces similar

tissue changes wherever it occurs, a single diagnostic code and set of

evaluation criteria are adequate; we have, however, revised the

criteria to more accurately reflect the range of effects that cold

injury may produce, such as arthralgia, tissue loss, nail

abnormalities, and color changes. We have also deleted the bilateral

evaluations contained in the prior schedule in favor of evaluating each

affected part separately and combining them for the overall evaluation

for cold injury, a change which is similar to changes we have made in

the method of evaluating peripheral arterial and venous diseases of the

extremities. In the case of paired extremities, the evaluations will be

combined, if appropriate, in accordance with Secs. 4.25 and 4.26 (as

described in Note (2), added following DC 7122).

The proposed note following DC 7122 directed that higher ratings

could be assigned, if warranted, because of loss of toes, by reference

to amputation ratings. We have edited this Note (1) for clarity and

added a statement about the evaluation of complications such as

peripheral neuropathy or squamous cell carcinoma of the skin at the

site of a scar.

One commenter requested that we include neurologic symptoms

associated with exposure to low or subfreezing temperatures in the

evaluation criteria for DC 7122, cold injuries.

In response to this suggestion, we have added numbness or locally

impaired sensation, which are neurologic symptoms, to the evaluation

criteria.

One individual suggested that cold injuries of the hands are

generally more disabling than those of the lower extremities.

The severity of cold injuries to various parts of the body depends

on such factors as the extent and duration of exposure, more than on

the particular part affected. We have provided evaluation criteria

that, applied with the notes regarding amputations and complications,

are flexible enough to cover a broad range of severity and allow

evaluation of any extent of tissue damage from cold injury to any body

part, so we have not adopted any changes based on this comment.

The current schedule provides six months of convalescence

evaluation for soft tissue sarcoma of vascular origin (DC 7123). We

proposed that a total evaluation be assigned indefinitely, with a

mandatory VA examination to be conducted six months following the

completion of therapy. One commenter recommended that we allow one year

of convalescence evaluation.

We believe that an examination six months following the cessation

of treatment affords sufficient time for convalescence and

stabilization of residuals, particularly since the rule requires only

an examination, not a reduction, at that time. In our judgment, this

method of determining the length of the total evaluation is both fairer

and more accurate than assigning a total evaluation for a specified

length of time, since the evaluation will be based on actual residual

disability as documented by the examination, and the veteran will

receive advance notice of any change and have the opportunity to submit

additional evidence showing that the change is not warranted.

Two commenters requested that VA provide a zero-percent evaluation

for all diagnostic codes.

On October 6, 1993, VA revised its regulation addressing the issue

zero-percent evaluations (38 CFR 4.31) to authorize assignment of a

zero-percent evaluation for any disability in the rating schedule when

minimum requirements for a compensable evaluation are not met. In

general, that regulatory provision precludes the need for zero-percent

evaluation criteria.

On further review, we have revised the title of DC 7121 from

``phlebitis or thrombophlebitis'' to ``post-phlebitic syndrome of any

etiology'' because both superficial and deep acute thrombophlebitis are

transient conditions, but it is the chronic form of thrombophlebitis

with venous insufficiency, known as ``postphlebitic leg,''

``postphlebitic sequelae of chronic venous insufficiency,''

``postphlebitic syndrome,'' or ``stasis syndrome,'' that may follow

thrombophlebitis. This is not a substantive change.

[[Page 65219]]

For the sake of clarity, we have made nonsubstantive changes in the

notes under ventricular arrhythmias (DC 7011), heart valve replacement

(DC 7016), cardiac transplantation (DC 7019), aortic aneurysm (DC

7110), aneurysm, any large artery (DC 7111), and soft tissue sarcoma

(DC 7123).

VA appreciates the comments submitted in response to the proposed

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

The Secretary hereby certifies that this regulatory amendment will

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

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

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

amendment would not directly affect any small entities. Only VA

beneficiaries could be directly affected. Therefore, pursuant to 5

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

regulatory flexibility analysis requirements of sections 603 and 604.

This regulatory amendment has been reviewed by the Office of

Management and Budget under the provisions of Executive Order 12866,

Regulatory Planning and Review, dated September 30, 1993.

The Catalog of Federal Domestic Assistance program numbers are

64.104 and 64.109.

List of Subjects in 38 CFR Part 4

Disability benefits, Individuals with disabilities, Pensions,

Veterans.

Approved: August 7, 1997.

Hershel W. Gober,

Acting Secretary of Veterans Affairs.

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

is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

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

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

Subpart B--Disability Ratings

Secs. 4.100 through 4.102 [Removed and Reserved]

2. Sections 4.100, 4.101, 4.102 are removed and reserved.

3. Section 4.104 is revised to read as follows:

Sec. 4.104 Schedule of ratings--cardiovascular system.

Diseases of the Heart

Note (1): Evaluate cor pulmonale, which is a form of secondary heart

disease, as part of the pulmonary condition that causes it.

Note (2): One MET (metabolic equivalent) is the energy cost of

standing quietly at rest and represents an oxygen uptake of 3.5

milliliters per kilogram of body weight per minute. When the level

of METs at which dyspnea, fatigue, angina, dizziness, or syncope

develops is required for evaluation, and a laboratory determination

of METs by exercise testing cannot be done for medical reasons, an

estimation by a medical examiner of the level of activity (expressed

in METs and supported by specific examples, such as slow stair

climbing or shoveling snow) that results in dyspnea, fatigue,

angina, dizziness, or syncope may be used.

------------------------------------------------------------------------

Rating

------------------------------------------------------------------------

7000 Valvular heart disease (including rheumatic heart

disease):

During active infection with valvular heart damage and

for three months following cessation of therapy for

the active infection.................................. 100

Thereafter, with valvular heart disease (documented by

findings on physical examination and either

echocardiogram, Doppler echocardiogram, or cardiac

catheterization) resulting in:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electro-cardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7001 Endocarditis:

For three months following cessation of therapy for

active infection with cardiac involvement............. 100

Thereafter, with endocarditis (documented by findings

on physical examination and either echocardiogram,

Doppler echocardiogram, or cardiac catheterization)

resulting in:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7002 Pericarditis:

For three months following cessation of therapy for

active infection with cardiac involvement............. 100

Thereafter, with documented pericarditis resulting in:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electro-cardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

[[Page 65220]]

7003 Pericardial adhesions:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electro-cardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7004 Syphilitic heart disease:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

Note: Evaluate syphilitic aortic aneurysms under DC 7110

(aortic aneurysm).

7005 Arteriosclerotic heart disease (Coronary artery

disease):

With documented coronary artery disease resulting in:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

Note: If nonservice-connected arteriosclerotic heart

disease is superimposed on service-connected valvular or

other non-arteriosclerotic heart disease, request a

medical opinion as to which condition is causing the

current signs and symptoms.

7006 Myocardial infarction:

During and for three months following myocardial

infarction, documented by laboratory tests............ 100

Thereafter:

With history of documented myocardial infarction,

resulting in:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7007 Hypertensive heart disease:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7008 Hyperthyroid heart disease:

Include as part of the overall evaluation for

hyperthyroidism under DC 7900. However, when atrial

fibrillation is present, hyperthyroidism may be

evaluated either under DC 7900 or under DC 7010

(supraventricular arrhythmia), whichever results in a

higher evaluation.

7010 Supraventricular arrhythmias:

Paroxysmal atrial fibrillation or other

supraventricular tachycardia, with more than four

episodes per year documented by ECG or Holter monitor. 30

Permanent atrial fibrillation (lone atrial

fibrillation), or; one to four episodes per year of

paroxysmal atrial fibrillation or other

supraventricular tachycardia documented by ECG or

Holter monitor........................................ 10

7011 Ventricular arrhythmias (sustained):

For indefinite period from date of hospital admission

for initial evaluation and medical therapy for a

sustained ventricular arrhythmia, or; for indefinite

period from date of hospital admission for ventricular

aneurysmectomy, or; with an automatic implantable

Cardioverter-Defibrillator (AICD) in place............ 100

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

[[Page 65221]]

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

Note: A rating of 100 percent shall be assigned from the

date of hospital admission for initial evaluation and

medical therapy for a sustained ventricular arrhythmia or

for ventricular aneurysmectomy. Six months following

discharge, 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.

7015 Atrioventricular block:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication or a pacemaker

required.............................................. 10

Note: Unusual cases of arrhythmia such as atrioventricular

block associated with a supraventricular arrhythmia or

pathological bradycardia should be submitted to the

Director, Compensation and Pension Service. Simple delayed

P-R conduction time, in the absence of other evidence of

cardiac disease, is not a disability.

7016 Heart valve replacement (prosthesis):

For indefinite period following date of hospital

admission for valve replacement....................... 100

Thereafter:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

Note: A rating of 100 percent shall be assigned as of the

date of hospital admission for valve replacement. Six

months following discharge, 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.

7017 Coronary bypass surgery:

For three months following hospital admission for

surgery............................................... 100

Thereafter:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

7018 Implantable cardiac pacemakers:

For two months following hospital admission for

implantation or reimplantation........................ 100

Thereafter:

Evaluate as supraventricular arrhythmias (DC 7010),

ventricular arrhythmias (DC 7011), or atrioventricular

block (DC 7015). Minimum.............................. 10

Note: Evaluate implantable Cardioverter-Defibrillators

(AICD's) under DC 7011.

7019 Cardiac transplantation:

For an indefinite period from date of hospital

admission for cardiac transplantation................. 100

Thereafter:

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Minimum............................................ 30

Note: A rating of 100 percent shall be assigned as of the

date of hospital admission for cardiac transplantation.

One year following discharge, 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.

7020 Cardiomyopathy:

[[Page 65222]]

Chronic congestive heart failure, or; workload of 3

METs or less results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30

percent............................................... 100

More than one episode of acute congestive heart failure

in the past year, or; workload of greater than 3 METs

but not greater than 5 METs results in dyspnea,

fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of

30 to 50 percent...................................... 60

Workload of greater than 5 METs but not greater than 7

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; evidence of cardiac hypertrophy or

dilatation on electrocardiogram, echocardiogram, or X-

ray................................................... 30

Workload of greater than 7 METs but not greater than 10

METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; continuous medication required........ 10

Diseases of the Arteries and Veins

7101 Hypertensive vascular disease (hypertension and

isolated systolic hypertension):

Diastolic pressure predominantly 130 or more........... 60

Diastolic pressure predominantly 120 or more........... 40

Diastolic pressure predominantly 110 or more, or;

systolic pressure predominantly 200 or more........... 20

Diastolic pressure predominantly 100 or more, or;

systolic pressure predominantly 160 or more, or;

minimum evaluation for an individual with a history of

diastolic pressure predominantly 100 or more who

requires continuous medication for control............ 10

Note (1): Hypertension or isolated systolic hypertension

must be confirmed by readings taken two or more times on

at least three different days. For purposes of this

section, the term hypertension means that the diastolic

blood pressure is predominantly 90mm. or greater, and

isolated systolic hypertension means that the systolic

blood pressure is predominantly 160mm. or greater with a

diastolic blood pressure of less than 90mm.

Note (2): Evaluate hypertension due to aortic insufficiency

or hyperthyroidism, which is usually the isolated systolic

type, as part of the condition causing it rather than by a

separate evaluation.

7110 Aortic aneurysm:

If five centimeters or larger in diameter, or; if

symptomatic, or; for indefinite period from date of

hospital admission for surgical correction (including

any type of graft insertion).......................... 100

Precluding exertion.................................... 60

Evaluate residuals of surgical correction according to

organ systems affected.

Note: A rating of 100 percent shall be assigned as of the

date of admission for surgical correction. Six months

following discharge, 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.

7111 Aneurysm, any large artery:

If symptomatic, or; for indefinite period from date of

hospital admission for surgical correction............ 100

Following surgery:

Ischemic limb pain at rest, and; either deep ischemic

ulcers or ankle/brachial index of 0.4 or less......... 100

Claudication on walking less than 25 yards on a level

grade at 2 miles per hour, and; persistent coldness of

the extremity, one or more deep ischemic ulcers, or

ankle/brachial index of 0.5 or less................... 60

Claudication on walking between 25 and 100 yards on a

level grade at 2 miles per hour, and; trophic changes

(thin skin, absence of hair, dystrophic nails) or

ankle/brachial index of 0.7 or less................... 40

Claudication on walking more than 100 yards, and;

diminished peripheral pulses or ankle/brachial index

of 0.9 or less........................................ 20

Note (1): The ankle/brachial index is the ratio of the

systolic blood pressure at the ankle (determined by

Doppler study) divided by the simultaneous brachial artery

systolic blood pressure. The normal index is 1.0 or

greater.

Note (2): These evaluations are for involvement of a single

extremity. If more than one extremity is affected,

evaluate each extremity separately and combine (under Sec.

4.25), using the bilateral factor, if applicable.

Note (3): A rating of 100 percent shall be assigned as of

the date of hospital admission for surgical correction.

Six months following discharge, 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.

7112 Aneurysm, any small artery:

Asymptomatic........................................... 0

Note: If symptomatic, evaluate according to body system

affected. Following surgery, evaluate residuals under the

body system affected.

7113 Arteriovenous fistula, traumatic:

With high output heart failure......................... 100

Without heart failure but with enlarged heart, wide

pulse pressure, and tachycardia....................... 60

Without cardiac involvement but with edema, stasis

dermatitis, and either ulceration or cellulitis:

Lower extremity.................................... 50

Upper extremity.................................... 40

With edema or stasis dermatitis:

Lower extremity.................................... 30

Upper extremity.................................... 20

7114 Arteriosclerosis obliterans:

Ischemic limb pain at rest, and; either deep ischemic

ulcers or ankle/brachial index of 0.4 or less......... 100

Claudication on walking less than 25 yards on a level

grade at 2 miles per hour, and; either persistent

coldness of the extremity or ankle/brachial index of

0.5 or less........................................... 60

Claudication on walking between 25 and 100 yards on a

level grade at 2 miles per hour, and; trophic changes

(thin skin, absence of hair, dystrophic nails) or

ankle/brachial index of 0.7 or less................... 40

Claudication on walking more than 100 yards, and;

diminished peripheral pulses or ankle/brachial index

of 0.9 or less........................................ 20

Note (1): The ankle/brachial index is the ratio of the

systolic blood pressure at the ankle (determined by

Doppler study) divided by the simultaneous brachial artery

systolic blood pressure. The normal index is 1.0 or

greater.

Note (2): Evaluate residuals of aortic and large arterial

bypass surgery or arterial graft as arteriosclerosis

obliterans.

Note (3): These evaluations are for involvement of a single

extremity. If more than one extremity is affected,

evaluate each extremity separately and combine (under Sec.

4.25), using the bilateral factor (Sec. 4.26), if

applicable.

[[Page 65223]]

7115 Thrombo-angiitis obliterans (Buerger's Disease):

Ischemic limb pain at rest, and; either deep ischemic

ulcers or ankle/brachial index of 0.4 or less......... 100

Claudication on walking less than 25 yards on a level

grade at 2 miles per hour, and; either persistent

coldness of the extremity or ankle/brachial index of

0.5 or less........................................... 60

Claudication on walking between 25 and 100 yards on a

level grade at 2 miles per hour, and; trophic changes

(thin skin, absence of hair, dystrophic nails) or

ankle/brachial index of 0.7 or less................... 40

Claudication on walking more than 100 yards, and;

diminished peripheral pulses or ankle/brachial index

of 0.9 or less........................................ 20

Note (1): The ankle/brachial index is the ratio of the

systolic blood pressure at the ankle (determined by

Doppler study) divided by the simultaneous brachial artery

systolic blood pressure. The normal index is 1.0 or

greater.

Note (2): These evaluations are for involvement of a single

extremity. If more than one extremity is affected,

evaluate each extremity separately and combine (under Sec.

4.25), using the bilateral factor (Sec. 4.26), if

applicable.

7117 Raynaud's syndrome:

With two or more digital ulcers plus autoamputation of

one or more digits and history of characteristic

attacks............................................... 100

With two or more digital ulcers and history of

characteristic attacks................................ 60

Characteristic attacks occurring at least daily........ 40

Characteristic attacks occurring four to six times a

week.................................................. 20

Characteristic attacks occurring one to three times a

week.................................................. 10

Note: For purposes of this section, characteristic attacks

consist of sequential color changes of the digits of one

or more extremities lasting minutes to hours, sometimes

with pain and paresthesias, and precipitated by exposure

to cold or by emotional upsets. These evaluations are for

the disease as a whole, regardless of the number of

extremities involved or whether the nose and ears are

involved.

7118 Angioneurotic edema:

Attacks without laryngeal involvement lasting one to

seven days or longer and occurring more than eight

times a year, or; attacks with laryngeal involvement

of any duration occurring more than twice a year...... 40

Attacks without laryngeal involvement lasting one to

seven days and occurring five to eight times a year,

or; attacks with laryngeal involvement of any duration

occurring once or twice a year........................ 20

Attacks without laryngeal involvement lasting one to

seven days and occurring two to four times a year..... 10

7119 Erythromelalgia:

Characteristic attacks that occur more than once a day,

last an average of more than two hours each, respond

poorly to treatment, and that restrict most routine

daily activities...................................... 100

Characteristic attacks that occur more than once a day,

last an average of more than two hours each, and

respond poorly to treatment, but that do not restrict

most routine daily activities......................... 60

Characteristic attacks that occur daily or more often

but that respond to treatment......................... 30

Characteristic attacks that occur less than daily but

at least three times a week and that respond to

treatment............................................. 10

Note: For purposes of this section, a characteristic attack

of erythromelalgia consists of burning pain in the hands,

feet, or both, usually bilateral and symmetrical, with

increased skin temperature and redness, occurring at warm

ambient temperatures. These evaluations are for the

disease as a whole, regardless of the number of

extremities involved.

7120 Varicose veins:

With the following findings attributed to the effects

of varicose veins: Massive board-like edema with

constant pain at rest................................. 100

Persistent edema or subcutaneous induration, stasis

pigmentation or eczema, and persistent ulceration..... 60

Persistent edema and stasis pigmentation or eczema,

with or without intermittent ulceration............... 40

Persistent edema, incompletely relieved by elevation of

extremity, with or without beginning stasis

pigmentation or eczema................................ 20

Intermittent edema of extremity or aching and fatigue

in leg after prolonged standing or walking, with

symptoms relieved by elevation of extremity or

compression hosiery................................... 10

Asymptomatic palpable or visible varicose veins........ 0

Note: These evaluations are for involvement of a single

extremity. If more than one extremity is involved,

evaluate each extremity separately and combine (under Sec.

4.25), using the bilateral factor (Sec. 4.26), if

applicable.

7121 Post-phlebitic syndrome of any etiology:

With the following findings attributed to venous

disease:

Massive board-like edema with constant pain at rest 100

Persistent edema or subcutaneous induration, stasis

pigmentation or eczema, and persistent ulceration. 60

Persistent edema and stasis pigmentation or eczema,

with or without intermittent ulceration........... 40

Persistent edema, incompletely relieved by

elevation of extremity, with or without beginning

stasis pigmentation or eczema..................... 20

Intermittent edema of extremity or aching and

fatigue in leg after prolonged standing or

walking, with symptoms relieved by elevation of

extremity or compression hosiery.................. 10

Asymptomatic palpable or visible varicose veins.... 0

Note: These evaluations are for involvement of a single

extremity. If more than one extremity is involved,

evaluate each extremity separately and combine (under Sec.

4.25), using the bilateral factor (Sec. 4.26), if

applicable.

7122 Cold injury residuals:

With pain, numbness, cold sensitivity, or arthralgia

plus two or more of the following: tissue loss, nail

abnormalities, color changes, locally impaired

sensation, hyperhidrosis, X-ray abnormalities

(osteoporosis, subarticular punched out lesions, or

osteoarthritis) of affected parts..................... 30

With pain, numbness, cold sensitivity, or arthralgia

plus tissue loss, nail abnormalities, color changes,

locally impaired sensation, hyperhidrosis, or X-ray

abnormalities (osteoporosis, subarticular punched out

lesions, or osteoarthritis) of affected parts......... 20

With pain, numbness, cold sensitivity, or arthralgia... 10

Note (1): Amputations of fingers or toes, and complications

such as squamous cell carcinoma at the site of a cold

injury scar or peripheral neuropathy should be separately

evaluated under other diagnostic codes.

Note (2): Evaluate each affected part (hand, foot, ear,

nose) separately and combine the ratings, if appropriate,

in accordance with Secs. 4.25 and 4.26.

[[Page 65224]]

7123 Soft tissue sarcoma (of vascular origin)............. 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.

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

[FR Doc. 97-32413 Filed 12-10-97; 8:45 am]

BILLING CODE 8320-01-P