80 FR 32513 - Schedule for Rating Disabilities; The Organs of Special Sense and Schedule of Ratings-Eye

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 80, Issue 110 (June 9, 2015)

Page Range		32513-32522
FR Document		2015-13788

The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or rating schedule) that addresses the organs of special sense and schedule of ratings--eye. The purpose of these changes is to incorporate medical advances that have occurred since the last review, update current medical terminology, and provide clear evaluation criteria. The proposed rule reflects advances in medical knowledge, recommendations from the National Academy of Sciences (NAS), and comments from subject matter experts and the public garnered as part of a public forum. The public forum, focusing on revisions to the organs of special sense and schedule of ratings for eye disabilities, was held on January 19-20, 2012.

Federal Register, Volume 80 Issue 110 (Tuesday, June 9, 2015)

[Federal Register Volume 80, Number 110 (Tuesday, June 9, 2015)]
[Proposed Rules]
[Pages 32513-32522]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2015-13788]

[[Page 32513]]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP14

Schedule for Rating Disabilities; The Organs of Special Sense and
Schedule of Ratings--Eye

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the
portion of the VA Schedule for Rating Disabilities (VASRD or rating
schedule) that addresses the organs of special sense and schedule of
ratings--eye. The purpose of these changes is to incorporate medical
advances that have occurred since the last review, update current
medical terminology, and provide clear evaluation criteria. The
proposed rule reflects advances in medical knowledge, recommendations
from the National Academy of Sciences (NAS), and comments from subject
matter experts and the public garnered as part of a public forum. The
public forum, focusing on revisions to the organs of special sense and
schedule of ratings for eye disabilities, was held on January 19-20,
2012.

DATES: Comments must be received on or before August 10, 2015.

ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to Director, Office of
Regulation Policy and Management (02REG), Department of Veterans
Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; or by
fax to (202) 273-9026. Comments should indicate that they are submitted
in response to ``RIN 2900-AP14-Schedule for Rating Disabilities; The
Organs of Special Sense and Schedule of Ratings--Eye.'' Copies of
comments received will be available for public inspection in the Office
of Regulation Policy and Management, Room 1068, between the hours of
8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).
Please call (202) 461-4902 for an appointment. (This is not a toll-free
number.) In addition, during the comment period, comments may be viewed
online through the Federal Docket Management System (FDMS) at
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Nick Olmos-Lau, M.D., Medical Officer,
Part 4 VASRD Staff (211C), Compensation Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW.,
Washington, DC 20420, (202) 461-9700. (This is not a toll-free
telephone number.)

SUPPLEMENTARY INFORMATION: As part of VA's ongoing revision of the VA
Schedule for Rating Disabilities (VASRD or rating schedule), VA
proposes changes to 38 CFR 4.77-4.79, which pertain to the organs of
special sense and disabilities and disease of the eye. The proposed
changes will: (1) Update the medical terminology of certain eye
conditions; (2) add medical conditions frequently encountered but not
currently found in the rating schedule; and (3) refine evaluation
criteria based on medical advances that have occurred since the last
revision and current understanding of functional changes associated
with or resulting from disease or injury (pathophysiology).

I. Sec. 4.77 Visual Fields

Current Sec. 4.77(a) requires examiners to record the results of
visual field testing on a standard Goldmann chart and include the
Goldmann chart with the examination report. In order to improve the
efficiency and timeliness of claims processing, VA proposes to
eliminate the requirement that examiners provide VA with the Goldmann
chart and instead only require the visual field measurements necessary
for rating purposes.
An examination of visual fields requires an examiner to indicate
the Veteran's maximum visual field at 16 prescribed points of
measurement. Under the current regulation, if the results of an
examination do not include the Goldmann chart used for visual field
testing, it must be returned to the examiner for inclusion of the
completed chart prior to evaluating the disability. This results in
unnecessary delays in claims where all relevant information to evaluate
visual field impairment is present, but is not in the prescribed
format. In addition to reducing delays in processing time, eliminating
the chart requirement expands the ability to evaluate disabilities on
the basis of private treatment records, provided they contain
sufficient evidence to evaluate the disability. Under the proposed
change, an examination of a visual field impairment is sufficient for
rating purposes if it provides, at a minimum, visual field measurements
of at least 16 meridians 22\1/2\ degrees apart for each eye and it
indicates the Goldmann equivalent used during testing. As this
information need not be provided in a chart format, VA proposes to
amend in current paragraph (a) the phrase ``The examiner must chart at
least 16 meridians . . .'' to read ``The examiner must document the
results for at least 16 meridians . . .''.
Similarly, VA proposes to amend the language in current paragraph
(a) which directs an examiner to ``include the tracing of either the
tangent screen or of the 30-degree threshold visual field . . .'' when
additional testing is required. As above, VA proposes that the examiner
need only ``document the results'' of the additional testing rather
than provide the actual tracing itself.
No other changes to Sec. 4.77 are proposed.

II. Sec. 4.78 Muscle Function

Section 4.78(a) currently requires muscle function to be examined
and measured using Goldmann perimeters. However, due to the increasing
difficulty encountered by evaluation facilities in acquiring and
repairing Goldmann perimeters, the Tangent Screen has been developed as
an alternative method for documenting alteration of eye muscle
function. David F. Chang, Chapter 2. Ophthalmologic Examination,
Vaughan & Asbury's General Ophthalmology, http://accessmedicine.mhmedical.com/content.aspx?bookid=387&Sectionid=40229319
(last visited Apr. 29, 2014). The Tangent Screen is an inexpensive
device, commonly found in many eye clinics, and is used to test for
diplopia due to eye muscle dysfunction. Like the Goldmann perimeter,
the results of the Tangent Screen method are documented on a Goldmann
chart recording sheet, which plots areas of diplopia across the major
visual fields. Furthermore, the results of both tests are relatively
similar. See Agnes M.F. Wong, MD, and James A. Sharpe, MD, A Comparison
of Tangent Screen, Goldmann, and Humphrey Perimetry in the Detection
and Localization of Occipital Lesions, Ophthalmology 1107:527-544
(2000). In order to accommodate more modern and readily available
methods, VA proposes to amend Sec. 4.78(a) to allow for measurement of
muscle function using either Goldmann perimeters or Tangent Screen
method.
Current Sec. 4.78(a) requires examiners to plot the results of
muscle function testing on a standard Goldmann chart and include the
chart with the examination report. VA proposes to remove these
requirements for the same reasons indicated in the section above
discussing proposed changes to Sec. 4.77. Under the proposed change,
an examination of muscle function is sufficient for rating purposes if
it identifies the quadrant(s) and range(s) of degrees in which diplopia
exists.
No other changes to Sec. 4.78 are proposed.

[[Page 32514]]

III. Sec. 4.79 Schedule of Ratings--Eye

Current Sec. 4.79 contains a General Rating Formula for Diagnostic
Codes 6000 through 6009. This formula evaluates disease of the eye on
the basis of incapacitating episodes or visual impairment (impairment
of visual acuity, visual field, and/or muscle function), whichever
provides the highest evaluation. Currently, ``incapacitating episodes''
is defined as a period of acute symptoms severe enough to require
prescribed bed rest and treatment by a physician or other healthcare
provider. This definition provides limited applicability of the rating
formula as bed rest is no longer a uniformly valid method of treatment,
nor is it a pertinent domain in the field of disability criteria. R.I.
Cho & E. Savitsky, Ocular Trauma, Combat Casualty Care: Lessons Learned
from OEF and OIF, 299 (M. Lenhart ed. 2012). Limiting the definition to
bed rest categorically excludes periods of incapacitation due to eye
disease requiring intensive treatment and medical management other than
bed rest, as well as the potential for development of medical
complications. Therefore, VA proposes to update the definition of an
incapacitating episode to mean an episode that requires clinic visits
for treatment for an active eye disease.
Through its definition, VA intends to require that these visits be
documented in the medical record by a physician or other health care
provider and that such visits must relate to the monitoring of
progress, administration of treatment(s), and the development of
complications related to the underlying active eye disability.
Incorporating documented treatment allows for consideration of
intensive interventional care, the use of complex drugs, and the
placement of devices when evaluating the severity of a given eye
disability. By providing evaluations based on the duration of treatment
for an active eye disease, the proposed criteria more accurately
reflect occupational disruption and impairment due to eye diseases that
do not necessarily involve measurable visual impairment. This updated
definition of incapacitating episodes aligns with modern medical
practice and the treatment of eye diseases, providing an alternative
basis for evaluation of eye disabilities in the absence of visual
impairment. VA also proposes to add a non-exhaustive list of examples
of treatment to the definition of incapacitating episodes. This list
would clarify the evaluation criteria to claims processors and ease
application of the rating schedule by indicating possible treatment
options for the various eye diseases.
VA proposes a 60 percent evaluation for documented incapacitating
episodes requiring 10 or more medical visits for monitoring or
treatment of an active eye disease or complications per year. A 40
percent evaluation is proposed for documented incapacitating episodes
requiring at least 7 but no more than 9 medical visits for monitoring
or treatment of an active eye disease or complications per year. A 20
percent evaluation is proposed for documented incapacitating episodes
requiring at least 4 but no more than 6 medical visits for monitoring
or treatment of an active eye disease or complications per year. VA
proposes a 10 percent evaluation for documented incapacitating episodes
requiring 3 medical visits for monitoring or treatment of an active eye
disease or complications per year.
VA would add a note to Sec. 4.79 that would refer raters, when
evaluating visual impairment due to the particular condition, to 38 CFR
4.75-4.78 and to Sec. 4.79, diagnostic codes 6061-6090.

A. Diseases of the Eye--Organizational Headings

The current schedule of ratings for the eye contains one general
category for Diseases of the Eye with a limited listing of diagnoses
and/or disabilities. This category does not organize the listed
disabilities in a manner that represents the current scientific
understanding of the specific anatomy of the eye, etiology of the
disease, or the disabling effect of the disease itself. When presented
with a diagnosis that is not listed in the rating schedule, claims
processors must rate by analogy to a listed diagnosis.
Section 4.27 directs claims processors to analogize these
disabilities on the basis of disease similarity and residual disability
to allow for easy identification of the source of each rating. However,
it is specifically noted that ``the diagnostic terminology will be that
of the medical examiner, with no attempt to translate the terms into
schedule nomenclature.'' Id. In other words, the determination of
disease type and residual disability is to be made by a medical
professional; the claims processor should not partake in any type of
medical determination when deciding how to rate analogously.
In order to ease the use of analogous codes when evaluating eye
diseases, VA proposes to organize the Diseases of the Eye into nine
categories. These diagnostic categories organize the listed
disabilities into medically logical sets on the basis of diagnostic
criteria, anatomical location, and disease etiology. By grouping
disabilities according to medical criteria, the categories would ease
the use of analogous coding by claims processors. Additionally, the
categories would allow VA to track the use of analogous codes with more
specificity, providing data on the need for inclusion of new
disabilities in future revisions to the VASRD.
All disabilities contained in Sec. 4.79 would be evaluated under
the General Rating Formula for Diseases of the Eye unless otherwise
directed. The organizational categories and specific diagnostic codes
within each category are as follows:

B. Diseases of the Uveal Tract

The uveal tract consists of three eye structures: the iris, the
ciliary body, and the choroid. This category of conditions includes
infections, inflammations including Tuberculosis of the eye (DC 6010)
and other diseases involving these three structures of the eye. This
category would include the following diagnostic codes (DCs): DC 6000,
choroidopathy, including uveitis, iritis, cyclitis, and choroiditis;
and DC 6002, scleritis. VA proposes to continue evaluating both
conditions under the General Rating Formula for Diseases of the Eye, as
amended above.

C. Diseases of the Retina, Macula, and Vitreous

The retina is the inner layer of the eye, containing blood vessels
and nerve structures that connect the eye with the optic nerve and
brain. The retina participates in light, motion, and color perception
and image formation. The macula is the visual center of the eye and
contains receptors that perceive light and color. Vitreous is the
thick, transparent substance that fills the eye, providing it with
volume and shape. This category includes the following diagnostic
codes:
1. Diagnostic Code 6006
Current DC 6006 addresses retinopathy or maculopathy. VA proposes
to clarify this code as ``not otherwise specified,'' as new DCs are
proposed to capture other specified types of retinopathy. If the
retinopathy diagnosed is not one of the other specified diagnoses, it
will be evaluated as DC 6006. This condition would continue to be
evaluated under the General Rating Formula for Diseases of the Eye.
2. Diagnostic Code 6008
VA proposes to continue evaluating this condition, detachment of
the retina, under the General Rating Formula for Diseases of the Eye.
VA proposes no other changes to this diagnostic code.

[[Page 32515]]

3. Diagnostic Code 6011
Current DC 6011 instructs claims processors to evaluate retinal
scars, atrophy, or irregularities as 10 percent disabling if such
scars, etc., are centrally located and result in an irregular,
duplicated, enlarged, or diminished image. Alternatively, claims
processors may evaluate based on visual impairment. VA proposes to
further expand this alternate rating criteria by directing claims
processors to evaluate this condition under the General Rating Formula
for Diseases of the Eye if this would result in a higher evaluation. In
other words, the only change to the diagnostic code is to allow this
condition to be evaluated on the basis of ``incapacitating episodes,''
in addition to visual impairment or the nature of the scar, atrophy, or
irregularity itself.
4. New Diagnostic Code 6040
VA proposes to add a new DC 6040, titled ``Diabetic retinopathy,''
in order to account for retinal impairment specifically caused by
diabetes in the Veteran population. Visual impairment is a common
complication of diabetes mellitus. Diabetes is the most significant
cause of visual impairment and blindness in the United States in
working age adults. James Orcutt et al., Eye Disease in Veterans with
Diabetes, 27 Diabetes Care B50 (2004). Epidemiologic studies of
diabetic retinopathy show that 15 years after the onset of diabetes,
retinopathy appears in 97 percent of patients with type 1 diabetes, 80
percent of type 2 diabetes treated with insulin, and 55 percent of type
2 diabetes treated without insulin. Id. The most severe form of
retinopathy (proliferative) was evident 15 years after the initial
diagnosis of diabetes in 30 percent of cases with type 1 diabetes, in
15 percent of those with type 2 diabetes treated with insulin, and in 5
percent of those not treated with insulin. Id. Of 429,918 patients
treated at the VA hospital with diabetes in 1998, 9.5 percent developed
proliferative retinopathy related to diabetes. In addition, the study
noted that diabetic veterans with lower-extremity amputations have an
increased risk for developing diabetic retinopathy. Id. at 52.
Currently, this condition is evaluated under DC 6006 (retinopathy
or maculopathy) without any method of identifying those cases caused by
diabetes. Given the significance of diabetes in the Veteran population
and the likelihood of developing this related eye disease, VA proposes
to add a separate diagnostic code to properly track and evaluate the
Veteran population with diabetic retinopathy. VA proposes to continue
evaluating this condition under the General Rating Formula for Diseases
of the Eye.
5. New Diagnostic Code 6042
VA proposes to add a new DC 6042, titled ``Retinal dystrophy
(including retinitis pigmentosa),'' in order to account for impairment
due to this condition in the Veteran population. Retinal dystrophy is
an important and growing group of disorders that cause blindness.
Included within the larger group of retinal dystrophy is retinitis
pigmentosa, perhaps the best known and most commonly recognized
condition. While retinitis pigmentosa is hereditary, the onset of
symptoms may be delayed until early adult years, meaning impairment may
not manifest until well after an individual has begun his or her
military service. In certain situations, disability compensation can be
provided to Veterans with this condition when the symptoms first
manifest themselves during active duty military service. To reinforce
the potential for service-connection for these disabilities, VA
proposes to add a specific diagnostic code for these conditions.
In retinitis pigmentosa there is a gradual loss of the eye
photoreceptors (rods and cones) with a deposition of pigment caused by
involutional changes of the cells of the retinal pigment epithelium
layer. Retinitis pigmentosa, A.D.A.M. Medical Encyclopedia, PubMed
Health, U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002024/ (last visited Apr. 29, 2014). This leads to
the gradual onset of night blindness, tripping over objects in the
visual periphery due to constricion of the peripheral visual field,
tunnel vision, and eventually total blindness. Id. There is currently
no known effective treatment for this condition. Id. Given the
functional effects of this disability, VA proposes to evaluate this
condition under the General Rating Formula for Diseases of the Eye,
which would allow for rating based on either visual impairment or on
incapacitating episodes.

D. Glaucoma

Glaucoma is a group of diseases that can damage the eye's optic
nerve and can result in loss of vision. Glaucoma, MayoClinic, http://www.mayoclinic.org/diseases-conditions/glaucoma/basics/symptoms/con-20024042 (last visited Apr. 29, 2014). The most common types of
glaucoma are open-angle glaucoma and angle-closure glaucoma. Id.
Angle closure glaucoma is due to a blockage of the fluid (aqueous
humor) drainage canals, causing a rapid and dangerous increase in eye
pressure. This is an acute emergency that can lead to permanent visual
loss. These conditions can be primary or secondary to an injury,
medication, inflammation, tumor, or other medical condition. Id. This
category includes the following diagnostic codes:
1. Diagnostic Code 6012
Current DC 6012, angle-closure glaucoma, lists evaluation criteria
based on either visual impairment or on incapacitating episodes,
whichever results in a higher evaluation. In addition, a minimum 10
percent evaluation is provided for the requirement of continuous
medication. For clarity and uniformity with the remainder of Sec.
4.79, VA proposes to include the general instruction to evaluate this
disability under the General Rating Formula for Diseases of the Eye
with a minimum evaluation of 10 percent when continuous medication is
required.
2. Diagnostic Code 6013
Current DC 6013, open-angle glaucoma, states to evaluate on the
basis of visual impairment due to this condition. VA proposes to direct
evaluation under the General Rating Formula for Diseases of the Eye,
which includes evaluation on the basis of visual impairment or
incapacitating episodes, whichever provides a higher evaluation. This
proposal expands the evaluation criteria to provide an alternative
measure of disability outside the realm of visual impairment for this
disability, allowing VA to more accurately and adequately capture the
disabling effects.
Current DC 6013 also provides a minimum 10 percent evaluation if
continuous medication is required for treatment. VA proposes no change
to this minimum evaluation.

E. Ocular Neoplasms and Trauma

This category includes current diagnostic codes for neoplasms of
the eye (both malingnant and benign) as well as eye traumas. This
category includes the following diagnostic codes:
1. Diagnostic Code 6007
VA proposes to continue evaluating DC 6007, intraocular hemorrhage,
under the General Rating Formula for Diseases of the Eye. VA proposes
no other changes to this diagnostic code.

[[Page 32516]]

2. Diagnostic Code 6009
Current DC 6009, unhealed eye injury, includes orbital trauma, as
well as penetrating and non-penetrating eye injury. VA proposes to
continue evaluating this condition under the General Rating Formula for
Diseases of the Eye. VA also proposes to add a note stating that this
code includes orbital trauma, as well as penetrating and non-
penetrating eye injury. This note would facilitate the identification
and recording of significant eye injuries in one DC.
3. Diagnostic Code 6014
Current DC 6014 evaluates malignant neoplasm of the eyeball only.
VA proposes to replace the word ``eyeball'' with ``eye'' to conform
with modern medical terminology. The preferred nomenclature in medicine
for the organ of vision is the eye. While eyeball and eye are used
interchangeably, it is customary to use the word eye when referring to
diseases or anatomy. American Academy of Ophthalmology, Introducing
Ophthalmology: A Primer for Office Staff, 8 (3d ed. 2013).
Additionally, VA proposes to clarify that this diagnostic code includes
malignant neoplasms of the orbit and adnexa. The most prevalent
intraocular malignant neoplasms include uveal melanoma, intraocular
lymphoma, and intraocular metastasis. These malignancies affect not
only the eyeball, but often involve the orbit and adnexa. To ensure
these malignancies are adequately evaluated under the VASRD, VA
proposes to clarify that DC 6014 is not limited to neoplasms of the
eyeball only. Malignant neoplasms of the skin are still excluded as
these are evaluated under current DC 7818 within a different body
system. VA proposes no changes to the evaluation criteria for DC 6014.
4. Diagnostic Code 6015
Current DC 6015 evaluates benign neoplasm of the eyeball and adnexa
only. VA proposes to replace the word ``eyeball'' with ``eye'' to
conform with modern medical terminology. Id. Additionally, VA proposes
to expand the applicability of this diagnostic code to include benign
neoplasms of the orbit, this includes lid tumors in adults, cavernous
hemangioma, dermoid, epidermal cysts and other conditions. By expanding
the applicability, the VASRD would provide a specific diagnostic code
for the evaluation of benign growths of the orbit and adnexa. Benign
neoplasms of the skin are still excluded as these are evaluated under
current DC 7819 within a different body system. VA proposes no changes
to the evaluation criteria for DC 6015.

F. Conditions of the Lacrimal System

The lacrimal system consists of the lacrimal glands and the
nasolacrimal duct. This system is responsible for the secretion and
drainage of tears and, when properly functioning, serves to moisten,
lubricate, and protect the surface of the eye. Cat N. Burkat MD, and
Mark J. Lucarelli MD, Anatomy of the Lacrimal System, The Lacrimal
System: Diagnosis, Management, and Surgery, http://link.springer.com/book/10.1007%2F978-0-387-35267-1. This category includes DC 6025, which
pertains to disorders of the lacrimal apparatus (epiphora,
dacrocystitis, etc.). VA proposes no changes to this diagnostic code.

G. Corneal Diseases

The cornea is the eye's outermost layer. It is a clear, dome-shaped
surface, overlying the pupil, that covers the front of the eye. Facts
About the Cornea and Corneal Disease, National Eye Institute, http://www.nei.nih.gov/health/cornealdisease/ (last visited Apr. 29, 2014).
The cornea functions as a lens which focuses light on the retina. Id.
An injury to the cornea generally produces redness, itching, tearing,
and, depending on the severity of the injury, pain and blurring of
vision. Id. This category includes the following diagnostic codes:
1. Diagnostic Code 6001
VA proposes to continue evaluating DC 6001, keratopathy, under the
General Rating Formula for Diseases of the Eye. VA proposes no other
changes to this diagnostic code.
2. Diagnostic Codes 6017 and 6018
Current DC 6017 states to evaluate trachomatous conjunctivitis on
the basis of visual impairment when this condition is active, with a
minimum evaluation of 30 percent. Current DC 6018 states to evaluate
chronic conjunctivitis (nontrachomatous) on the basis of visual
impairment when this condition is active, with a minimum evaluation of
10 percent.
VA proposes to direct evaluation of active trachomatous and
nontrachomatous conjunctivitis under the General Rating Formula for
Diseases of the Eye, which includes evaluation on the basis of visual
impairment or incapacitating episodes, whichever provides a higher
evaluation. This proposal expands the evaluation criteria to provide an
alternative measure of disability outside the realm of visual
impairment for these disabilities, allowing VA to more accurately and
adequately capture the disabling effects. VA proposes to retain the
respective minimum evaluations for cases of active conjunctivitis.
Once conjunctivitis (trachomatous or nontrachomatous) is found to
be inactive, current DCs 6017 and 6018 state to evaluate based on
residuals, including visual impairment or disfigurement under DC 7800.
VA proposes no change to these evaluation criteria.
3. Diagnostic Code 6035
Current DC 6035 states to evaluate keratoconus on the basis of
visual impairment due to this condition. VA proposes to direct
evaluation under the General Rating Formula for Diseases of the Eye,
which includes evaluation on the basis of visual impairment or
incapacitating episodes, whichever provides a higher evaluation. This
proposal expands the evaluation criteria to provide an alternative
measure of disability outside the realm of visual impairment for this
disability, allowing VA to more accurately and adequately capture the
disabling effects.
4. Diagnostic Code 6036
Current DC 6036 states to evaluate status post corneal transplant
on the basis of visual impairment due to this condition, with a minimum
evaluation of 10 percent in the presence of pain, photophobia, and
glare sensitivity. VA proposes to direct evaluation under the General
Rating Formula for Diseases of the Eye, which includes evaluation on
the basis of visual impairment or incapacitating episodes, whichever
provides a higher evaluation. This proposal expands the evaluation
criteria to provide an alternative measure of disability outside the
realm of visual impairment for this disability, allowing VA to more
accurately and adequately capture the disabling effects. VA intends to
retain the minimum evaluation of 10 percent in the presence of pain,
photophobia, and glare sensitivity.

H. External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow

The external eye disease category consists of a group of conditions
involving the ocular-related structures, which have direct contact with
the environment, and includes the eyelids, eyelashes, and eyebrows.
While the cornea has direct contact with the environment as well, VA
has provided a separate category for diseases of the cornea. The
external eye diseases category includes nine conditions of the
eyelashes, eyelids, and eyebrows listed in the current VASRD. This
category

[[Page 32517]]

includes the following diagnostic codes in which no change is proposed
to the current evaluation criteria: DC 6020, Ectropion; DC 6021,
Entropion; DC 6022, Lagophthalmos; DC 6023, Loss of eyebrows, complete,
unilateral or bilateral; DC 6024, Loss of eyelashes, complete,
unilateral or bilateral; DC 6032, Loss of eyelids, partial or complete;
and DC 6037, Pinguecula. It also includes the following diagnostic
codes with specific proposed changes.
Current DC 6034 states to evaluate pterygium on the basis of visual
impairment, disfigurement (DC 7800), conjunctivitis (DC 6018), etc.,
depending on the particular findings. Similarly, current DC 6091 states
to evaluate symblepharon on the basis of visual impairment,
lagophthalmos (DC 6022), disfigurement (DC 7800), etc., depending on
the particular findings.
In both cases, VA proposes to replace the direction to evaluate on
the basis of visual impairment with the General Rating Formula for
Diseases of the Eye, which includes evaluation on the basis of visual
impairment or incapacitating episodes, whichever provides a higher
evaluation. This proposal expands the evaluation criteria to provide an
alternative measure of disability outside the realm of visual
impairment for these disabilities, allowing VA to more accurately and
adequately capture the disabling effects. VA also proposes to include
the phrase ``and combine in accordance with Sec. 4.25'' to the rating
instructions of DCs 6034 and 6091. The current language allows for
multiple evaluations to be assigned and combined depending on the
particular findings, but it is not entirely clear to the reader.
Therefore, this addition would ensure consistency and clarity for field
application.
VA proposes no other changes to these diagnostic codes.

I. Disease of the Lens

The lens is a crystalline, transparent structure covered by a
capsule and suspended by a ligament that weakens with age. Henry Gray,
Anatomy of the Human Body, 1019-20 (20th ed. 1918). The lens capsule is
lined in the anterior portion by an epithelium that generates new lens
fibers at the equators. Id. In addition to malformation and
malposition, the main lens pathology is cataract formation. A cataract
is a lens opacity which produces visual impairment by obscuration and
altered light refraction. Facts About Cataract, National Eye Institute,
https://www.nei.nih.gov/health/cataract/cataract_facts.asp (last
visited Apr. 29, 2014). This category includes evaluation criteria for
DC 6029, Aphakia or dislocation of crystalline lens for which VA
proposes no changes. It also includes the following diagnostic codes
with specific proposed changes.
Current DC 6027 states to evaluate preoperative cataracts on the
basis of visual impairment. VA proposes to direct evaluation of
preoperative cataracts under the General Rating Formula for Diseases of
the Eye, which includes evaluation on the basis of visual impairment or
incapacitating episodes, whichever provides a higher evaluation. This
proposal expands the evaluation criteria to provide an alternative
measure of disability outside the realm of visual impairment for this
disability, allowing VA to more accurately and adequately capture the
disabling effects.
Current DC 6027 also provides two evaluation options for
postoperative cataracts depending on the presence or absence of a
replacement lens. If a replacement lens is present, current DC 6027
states to evaluate on the basis of visual impairment. VA proposes to
direct the evaluation of postoperative cataracts with a replacement
lens under the General Rating Formula for Diseases of the Eye for the
same reasons discussed above. If there is no replacement lens present,
current DC 6027 states to evaluate based on aphakia (DC 6029). VA
proposes only to insert the applicable DC. No substantive change is
proposed.

J. Neuro-Ophthalmic Conditions

This category includes a listing of the most common and pertinent
neuro-ophthalmic conditions, to include diseases of the anterior visual
pathways, optic nerve disorders, cranial nerve palsies resulting in
visual impairment, disorders of eye movements, and pupillary disorders.
The field of neuro-ophthalmology bridges the gap between neurology and
ophthalmology by providing particular attention to visual impairment
due to diseases of the neural structures involved in vision. Since a
substantial portion of the brain is involved with vision, many brain
disorders produce visual impairment. This category includes the
following diagnostic codes in which no change is proposed to the
current evaluation criteria: DC 6016, Nystagmus, central; DC 6019,
Ptosis, unilateral or bilateral; and DC 6030, Paralysis of
accommodation (due to neuropathy of the Oculomotor Nerve (cranial nerve
III)). It also includes the following diagnostic code with specific
proposes changes.
1. Diagnostic Code 6026
Current DC 6026 states to evaluate optic neuropathy on the basis of
visual impairment due to this condition. VA proposes to direct
evaluation under the General Rating Formula for Diseases of the Eye,
which includes evaluation on the basis of visual impairment or
incapacitating episodes, whichever provides a higher evaluation. This
proposal expands the evaluation criteria to provide an alternative
measure of disability outside the realm of visual impairment for this
disability, allowing VA to more accurately and adequately capture the
disabling effects.
2. New Diagnostic Code 6046
VA proposes to add a new DC 6046, titled ``Post-chiasmal
disorders.'' This category includes a variety of central visual
disorders with brain involvement. This category incorporates ophthalmic
residuals from traumatic brain injury (TBI) or other causes of cerebral
injury, such as infectious, vascular conditions, or degenerative
conditions. Post-chiasmal disorders may be associated with cognitive
changes caused by the structural or functional alteration of the brain
tissue, which are often associated with TBI. See James Garrity MD,
Overview of Optic Nerve Disorders, The Merck Manual Home Health
Handbook, http://www.merckmanuals.com/home/eye_disorders/optic_nerve_disorders/overview_of_optic_nerve_disorders.html (last
visited Apr. 29, 2014) (each optic nerve splits at a structure in the
brain called the optic chiasm). The alteration can lead to brain
dysfunction which can manifest as a variety of visual impairments.
Given the increased awareness and understanding of the chronic
residuals of TBI in the medical community, particularly amongst the
Veteran population, VA proposes this new diagnostic code to provide
adequate and proper evaluations for Veterans with post-chiasmal
disorders. Due to the varying presentation of post-chiasmal disorders,
VA proposes to evaluate these conditions under the General Rating
Formula for Diseases of the Eye to maximize the options available for
an accurate evaluation.

IV. Technical Amendments

VA also would update Appendix A, B, and C of part 4 to reflect the
above noted proposed amendments.

Executive Orders 12866 and 13563

Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory

[[Page 32518]]

approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, and other advantages;
distributive impacts; and equity). Executive Order 13563 (Improving
Regulation and Regulatory Review) emphasizes the importance of
quantifying both costs and benefits, reducing costs, harmonizing rules,
and promoting flexibility. Executive Order 12866 (Regulatory Planning
and Review) defines a ``significant regulatory action,'' which requires
review by the Office of Management and Budget (OMB), as ``any
regulatory action that is likely to result in a rule that may: (1) Have
an annual effect on the economy of $100 million or more or adversely
affect in a material way the economy, a sector of the economy,
productivity, competition, jobs, the environment, public health or
safety, or State, local, or tribal governments or communities; (2)
Create a serious inconsistency or otherwise interfere with an action
taken or planned by another agency; (3) Materially alter the budgetary
impact of entitlements, grants, user fees, or loan programs or the
rights and obligations of recipients thereof; or (4) Raise novel legal
or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in this Executive Order.''
The economic, interagency, budgetary, legal, and policy
implications of this proposed rule have been examined, and it has been
determined not to be a significant regulatory action under Executive
Order 12866. VA's impact analysis can be found as a supporting document
at http://www.regulations.gov, usually within 48 hours after the
rulemaking document is published. Additionally, a copy of this
rulemaking and its impact analysis are available on VA's Web site at
http://www.va.gov/orpm/, by following the link for ``VA Regulations
Published From FY 2004 Through Fiscal Year to Date.''

Regulatory Flexibility Act

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

Unfunded Mandates

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

Paperwork Reduction Act

This proposed rule contains no provisions constituting a collection
of information under the Paperwork Reduction Act of 1995 (44 U.S.C.
3501-3521).

Catalog of Federal Domestic Assistance

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

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this
document and authorized the undersigned to sign and submit the document
to the Office of the Federal Register for publication electronically as
an official document of the Department of Veterans Affairs. Robert A.
McDonald, Secretary of Veterans Affairs, approved this document on May
10, 2015, for publication.

List of Subjects in 38 CFR Part 4

Disability benefits, Pensions, Veterans.

Approved: June 2, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management.

For the reasons set out in the preamble, VA proposes to amend 38
CFR part 4, subpart B as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

0
1. The authority citation for part 4 continues to read as follows:

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

0
2. Amend Sec. 4.77 by revising paragraph (a) to read as follows:

Sec. 4.77 Visual fields.

(a) Examination of visual fields. Examiners must use either
Goldmann kinetic perimetry or automated perimetry using Humphrey Model
750, Octopus Model 101, or later versions of these perimetric devices
with simulated kinetic Goldmann testing capability. For phakic (normal)
individuals, as well as for pseudophakic or aphakic individuals who are
well adapted to intraocular lens implant or contact lens correction,
visual field examinations must be conducted using a standard target
size and luminance, which is Goldmann's equivalent III/4e. For aphakic
individuals not well adapted to contact lens correction or pseudophakic
individuals not well adapted to intraocular lens implant, visual field
examinations must be conducted using Goldmann's equivalent IV/4e. The
examiner must document the results for at least 16 meridians 22\1/2\
degrees apart for each eye and indicate the Goldmann equivalent used.
See Table III for the normal extent (in degrees) of the visual fields
at the 8 principal meridians (45 degrees apart). When the examiner
indicates that additional testing is necessary to evaluate visual
fields, the additional testing must be conducted using either a tangent
screen or a 30-degree threshold visual field with the Goldmann III
stimulus size. The examination report must document the results of
either the tangent screen or of the 30-degree threshold visual field
with the Goldmann III stimulus size.
* * * * *
0
3. Amend Sec. 4.78 by revising paragraph (a) to read as follows:

Sec. 4.78 Muscle function.

(a) Examination of muscle function. The examiner must use a
Goldmann perimeter chart or the Tangent Screen method that identifies
the four major quadrants (upward, downward, left and right lateral) and
the central field (20 degrees or less) (see Figure 2). The examiner
must document the results of muscle function testing by identifying the
quadrant(s) and range(s) of degrees in which diplopia exists.
* * * * *
0
4. Amend Sec. 4.79 Schedule of ratings--eye by revising the tables
Diseases of the Eye and Ratings for Impairment of Muscle Function to
read as follows:

[[Page 32519]]

Diseases of the Eye
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Unless otherwise directed, evaluate diseases of the eye under
the General Rating Formula for Diseases of the Eye.
General Rating Formula for Diseases of the Eye:
Evaluate on the basis of either visual impairment due to
the particular condition or on incapacitating episodes,
whichever results in a higher evaluation.
With documented incapacitating episodes requiring 10 or 60
more medical visits for monitoring or treatment of an
active eye disease or complications per year.............
With documented incapacitating episodes requiring at least 40
7 but no more than 9 medical visits for monitoring or
treatment of an active eye disease or complications per
year.....................................................
With documented incapacitating episodes requiring at least 20
4 but no more than 6 medical visits for monitoring or
treatment of an active eye disease or complications per
year.....................................................
With documented incapacitating episodes requiring 3 10
medical visits for monitoring or treatment of an active
eye disease or complications per year....................
Note (1): For the purposes of evaluation under 38 CFR
4.79, an incapacitating episode is one which requires
clinic visits for an active eye disease, as documented in
the medical record by a physician or other health care
provider, and relates to the monitoring of progress,
administration of treatment(s), and to the development of
complications related to the underlying active eye
disability. Examples of treatment may include but are not
limited to: Systemic immunosuppressants or biologic
agents; intravitreal or periocular injections; laser
treatments; or other surgical interventions.
Note (2): For the purposes of evaluating visual impairment
due to the particular condition, refer to 38 CFR 4.75-
4.78 and to Sec. 4.79, diagnostic codes 6061-6090.
------------------------------------------------------------------------
Diseases of the Uveal Tract
------------------------------------------------------------------------
6000 Choroidopathy, including uveitis, iritis, cyclitis, and
choroiditis.
6002 Scleritis.
6010 Tuberculosis of the eye:
Active.................................................... 100
Inactive: Evaluate under Sec. 4.88c or Sec. 4.89 of
this part, whichever is appropriate.
------------------------------------------------------------------------
Diseases of the Retina, Macula, and Vitreous
------------------------------------------------------------------------
6006 Retinopathy or maculopathy not otherwise specified.
6008 Detachment of retina.
6011 Retinal scars, atrophy, or irregularities:
Localized scars, atrophy, or irregularities of the retina, 10
unilateral or bilateral, that are centrally located and
that result in an irregular, duplicated, enlarged, or
diminished image.........................................
Alternatively, evaluate based on the General Rating
Formula for Diseases of the Eye, if this would result in
a higher evaluation.
6040 Diabetic retinopathy.
6042 Retinal dystrophy (including retinitis pigmentosa).
------------------------------------------------------------------------
Glaucoma
------------------------------------------------------------------------
6012 Angle-closure glaucoma.
Evaluate under the General Rating Formula for Diseases of 10
the Eye. Minimum evaluation if continuous medication is
required.................................................
6013 Open-angle glaucoma.
Evaluate under the General Rating Formula for Diseases of 10
the Eye. Minimum evaluation if continuous medication is
required.................................................
------------------------------------------------------------------------
Ocular Neoplasms and Trauma
------------------------------------------------------------------------
6007 Introacular hemorrhage.
6009 Unhealed eye injury.
Note: This code includes orbital trauma, as well as
penetrating and non-penetrating eye injury.
6014 Malignant neoplasms of the eye, orbit, and adnexa
(excluding skin):
Malignant neoplasms of the eye, orbit, and adnexa 100
(excluding skin) that require therapy that is comparable
to those used for systemic malignancies, i.e., systemic
chemotherapy, X-ray therapy more extensive than to the
area of the eye, or surgery more extensive than
enucleation..............................................
Note: Continue the 100-percent rating 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 will be determined by mandatory VA
examination. Any change in evaluation based upon that or
any subsequent examination will be subject to the
provisions of Sec. 3.105(e) of this chapter. If there
has been no local recurrence or metastasis, evaluate
based on residuals.
Malignant neoplasm of the eye, orbit, and adnexa
(excluding skin) that does not require therapy comparable
to that for systemic malignancies:
Separately evaluate visual impairment and nonvisual
impairment, e.g., disfigurement (diagnostic code
7800), and combine the evaluations.
6015 Benign neoplasms of the eye, orbit, and adnexa (excluding
skin):
Separately evaluate visual impairment and nonvisual
impairment, e.g., disfigurement (diagnostic code 7800),
and combine the evaluations.
------------------------------------------------------------------------
Conditions of the Lacrimal System
------------------------------------------------------------------------
6025 Disorders of the lacrimal apparatus (epiphora,
dacrocystitis, etc.):
Bilateral................................................. 20
Unilateral................................................ 10
------------------------------------------------------------------------

[[Page 32520]]

Corneal Diseases
------------------------------------------------------------------------
6001 Keratopathy.
6017 Trachomatous conjunctivitis:
Active: Evaluate under the General Rating Formula for 30
Diseases of the Eye, minimum rating......................
Inactive: Evaluate based on residuals, such as visual
impairment and disfigurement (diagnostic code 7800).
6018 Chronic conjunctivitis (nontrachomatous):
Active: Evaluate under the General Rating Formula for 10
Diseases of the Eye, minimum rating......................
Inactive: Evaluate based on residuals, such as visual
impairment and disfigurement (diagnostic code 7800).
6035 Keratoconus.
6036 Status post corneal transplant:
Rate under the General Rating Formula for Diseases of the
Eye.
Minimum, if there is pain, photophobia, and glare 10
sensitivity..........................................
------------------------------------------------------------------------
External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow
------------------------------------------------------------------------
6020 Ectropion:
Bilateral................................................. 20
Unilateral................................................ 10
6021 Entropion:
Bilateral................................................. 20
Unilateral................................................ 10
6022 Lagophthalmos:
Bilateral................................................. 20
Unilateral................................................ 10
6023 Loss of eyebrows, complete, unilateral or bilateral...... 10
6024 Loss of eyelashes, complete, unilateral or bilateral..... 10
6032 Loss of eyelids, partial or complete:
Separately evaluate both visual impairment due to eyelid
loss and nonvisual impairment, e.g., disfigurement
(diagnostic code 7800), and combine the evaluations.
6034 Pterygium:
Evaluate under the General Rating Formula for Diseases of
the Eye, disfigurement (diagnostic code 7800),
conjunctivitis (diagnostic code 6018), etc., depending on
the particular findings, and combine in accordance with
Sec. 4.25.
6037 Pinguecula:
Evaluate based on disfigurement (diagnostic code 7800).
6091 Symblepharon:
Evaluate under the General Rating Formula for Diseases of
the Eye, lagophthalmos (diagnostic code 6022),
disfigurement (diagnostic code 7800), etc., depending on
the particular findings, and combine in accordance with
Sec. 4.25.
------------------------------------------------------------------------
Disease of the Lens
------------------------------------------------------------------------
6027 Cataract:
Preoperative: Evaluate under the General Rating Formula
for Diseases of the Eye.
Postoperative: If a replacement lens is present
(pseudophakia), evaluate under the General Rating Formula
for Diseases of the Eye. If there is no replacement lens,
evaluate based on aphakia (diagnostic code 6029).
6029 Aphakia or dislocation of crystalline lens:
Evaluate based on visual impairment, and elevate the
resulting level of visual impairment one step.
Minimum (unilateral or bilateral)......................... 30
------------------------------------------------------------------------
Neuro-Ophthalmic Conditions
------------------------------------------------------------------------
6016 Nystagmus, central....................................... 10
6019 Ptosis, unilateral or bilateral:
Evaluate based on visual impairment or, in the absence of
visual impairment, on disfigurement (diagnostic code
7800).
6026 Optic neuropathy: Evaluate under the General Rating
Formula for Diseases of the Eye.
6030 Paralysis of accommodation (due to neuropathy of the 20
Oculomotor Nerve (cranial nerve III))........................
6046 Post-chiasmal disorders: Evaluate under the General
Rating Formula for Diseases of the Eye.
------------------------------------------------------------------------

Ratings for Impairment of Muscle Function
------------------------------------------------------------------------
Equivalent visual
Degree of diplopia acuity
------------------------------------------------------------------------
6090 Diplopia (double vision):
(a) Central 20 degrees........................... 5/200
(b) 21 degrees to 30 degrees..................... (1.5/60)
(1) Down
(2) Lateral.................................. 15/200
(3) Up....................................... (4.5/60)
(c) 31 degrees to 40 degrees..................... 20/100
(1) Down..................................... (6/30)
(2) Lateral.................................. 20/70 (6/21)

[[Page 32521]]

(3) Up
Note: In accordance with 38 CFR 4.31, diplopia 20/200 (6/60)
that is occasional or that is correctable with 20/70 (6/21)
spectacles is evaluated at 0 percent............ 20/40 (6/12)
------------------------------------------------------------------------
(Authority: 38 U.S.C. 1155).

0
5. In Appendix A to Part 4, add Sec. Sec. 4.77, 4.78, and 4.79 to read
as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------

* * * * * * *
4.77....................... .............. Revised [insert effective
date of final rule].
4.78....................... .............. Revised [insert effective
date of final rule].
4.79....................... .............. Introduction criterion
[insert effective date of
final rule]; Revised
General Rating Formula for
Diseases of the Eye
[insert effective date of
final rule]; General
Rating Formula for
Diseases of the Eye NOTE
revised [insert effective
date of final rule];
Organizational categories
added [insert effective
date of final rule].
6000 Criterion [insert effective
date of final rule].
6001 Criterion [insert effective
date of final rule].
6002 Criterion [insert effective
date of final rule].
6006 Title [insert effective
date of final rule];
criterion [insert
effective date of final
rule].
6007 Criterion [insert effective
date of final rule].
6008 Criterion [insert effective
date of final rule].
6009 Criterion [insert effective
date of final rule].
6011 Evaluation [insert
effective date of final
rule].
6012 Evaluation [insert
effective date of final
rule].
6013 Evaluation [insert
effective date of final
rule].
6014 Title [insert effective
date of final rule].
6015 Title [insert effective
date of final rule].
6017 Evaluation [insert
effective date of final
rule].
6018 Evaluation [insert
effective date of final
rule].
6019 Evaluation [insert
effective date of final
rule].
6026 Evaluation [insert
effective date of final
rule].
6027 Evaluation [insert
effective date of final
rule].
6034 Evaluation [insert
effective date of final
rule].
6035 Evaluation [insert
effective date of final
rule].
6036 Evaluation [insert
effective date of final
rule].
6040 Added [insert effective
date of final rule].
6042 Added [insert effective
date of final rule].
6046 Added [insert effective
date of final rule].
6091 Evaluation [insert
effective date of final
rule].

* * * * * * *
------------------------------------------------------------------------

0
6. In Appendix B to Part 4, The Eye, Diseases of the Eye, revise
diagnostic codes 6000, 6003-6005, 6006-6009, 6011-15, 6017-6018, 6026-
6027, 6034-6036, and add diagnostic codes 6040, 6042, and 6046 to read
as follows:

[[Page 32522]]

Appendix A to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------

* * * * *
THE EYE
Diseases of the Eye
------------------------------------------------------------------------

* * * * *
6000................................ Choroidopathy, including uveitis,
iritis, cyclitis, and
choroiditis.
6001................................ Keratopathy.
6002................................ Scleritis.
6006................................ Retinopathy or maculopathy not
otherwise specified.
6007................................ Intraocular hemorrhage.
6008................................ Detachment of retina.
6009................................ Unhealed eye injury.
6010................................ Tuberculosis of eye.
6011................................ Retinal scars, atrophy, or
irregularities.
6012................................ Angle-closure glaucoma.
6013................................ Open-angle glaucoma.
6014................................ Malignant neoplasms of the eye,
orbit, and adnexa (excluding
skin).
6015................................ Benign neoplasms of the eye,
orbit, and adnexa (excluding
skin).

* * * * *
6025................................ Disorders of the lacrimal
apparatus (epiphora,
dacrocystitis, etc.)
6026................................ Optic neuropathy.
6027................................ Cataract.

* * * * *
6034................................ Pterygium.
6035................................ Keratoconus.
6036................................ Status post corneal transplant.

* * * * *
6040................................ Diabetic retinopathy.
6042................................ Retinal dystrophy (including
retinitis pigmentosa).
6046................................ Post-chiasmal disorders.

* * * * *
------------------------------------------------------------------------

0
7. In Appendix C to Part 4, revise the disability entries for
diagnostic codes 6006, 6014, and 6015, and add disability entries for
Retinopathy, diabetic; Retinal dystrophy (including retinitis
pigmentosa); and Post-chiasmal disorders to read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
Diagnostic
code No.
------------------------------------------------------------------------

* * * * *
New growths:
Benign

* * * * *
Eye, orbit, and adnexa.......................... 6015

* * * * *
Eye, orbit, and adnexa.......................... 6014

* * * * *
Post-chiasmal disorders................................. 6046

* * * * *
Retinal dystrophy (including retinitis pigmentosa)...... 6042
Retinopathy, diabetic................................... 6040
Retinopathy or maculopathy not otherwise specified...... 6006

* * * * *
------------------------------------------------------------------------

[FR Doc. 2015-13788 Filed 6-8-15; 8:45 am]
BILLING CODE 8320-01-P

$Federal Register / Vol. 80, No. 110 / Tuesday, June 9, 2015 / Proposed Rules 32521 RATINGS FOR IMPAIRMENT OF MUSCLE FUNCTION—Continued Equivalent Degree of diplopia visual acuity (3) Up Note: In accordance with 38 CFR 4.31, diplopia that is occasional or that is correctable with spectacles is evaluated at 0 percent ............................................................................................................................................................................. 20/200 (6/60) 20/70 (6/21) 20/40 (6/12) (Authority: 38 U.S.C. 1155). ■ 5. In Appendix A to Part 4, add §§ 4.77, 4.78, and 4.79 to read as follows: APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946 Diagnostic Sec. code No. * * * * * * * 4.77 ................... ........................ Revised [insert effective date of final rule]. 4.78 ................... ........................ Revised [insert effective date of final rule]. 4.79 ................... ........................ Introduction criterion [insert effective date of final rule]; Revised General Rating Formula for Diseases of the Eye [insert effective date of final rule]; General Rating Formula for Diseases of the Eye NOTE revised [insert effective date of final rule]; Organizational categories added [insert effective date of final rule]. 6000 Criterion [insert effective date of final rule]. 6001 Criterion [insert effective date of final rule]. 6002 Criterion [insert effective date of final rule]. 6006 Title [insert effective date of final rule]; criterion [insert effective date of final rule]. 6007 Criterion [insert effective date of final rule]. 6008 Criterion [insert effective date of final rule]. 6009 Criterion [insert effective date of final rule]. 6011 Evaluation [insert effective date of final rule]. 6012 Evaluation [insert effective date of final rule]. 6013 Evaluation [insert effective date of final rule]. 6014 Title [insert effective date of final rule]. 6015 Title [insert effective date of final rule]. 6017 Evaluation [insert effective date of final rule]. 6018 Evaluation [insert effective date of final rule]. 6019 Evaluation [insert effective date of final rule]. 6026 Evaluation [insert effective date of final rule]. 6027 Evaluation [insert effective date of final rule]. 6034 Evaluation [insert effective date of final rule]. 6035 Evaluation [insert effective date of final rule]. 6036 Evaluation [insert effective date of final rule]. 6040 Added [insert effective date of final rule]. 6042 Added [insert effective date of final rule]. 6046 Added [insert effective date of final rule]. 6091 Evaluation [insert effective date of final rule]. * * * * * * * ■ 6. In Appendix B to Part 4, The Eye, codes 6000, 6003–6005, 6006–6009, 6036, and add diagnostic codes 6040, Diseases of the Eye, revise diagnostic 6011–15, 6017–6018, 6026–6027, 6034– 6042, and 6046 to read as follows: tkelley on DSK3SPTVN1PROD with PROPOSALS VerDate Sep<11>2014 17:11 Jun 08, 2015 Jkt 235001 PO 00000 Frm 00034 Fmt 4702 Sfmt 4702 E:\FR\FM\09JNP1.SGM 09JNP1$

32522 Federal Register / Vol. 80, No. 110 / Tuesday, June 9, 2015 / Proposed Rules

APPENDIX A TO PART 4—NUMERICAL APPENDIX C TO PART 4—ALPHABET- Document (TSD) prepared in support of
INDEX OF DISABILITIES ICAL INDEX OF DISABILITIES—Con- this rulemaking action. A copy of the
tinued TSD is available, upon request, from the
Diagnostic EPA Regional Office listed in the
code No. Diagnostic section of this document or
ADDRESSES
is also available electronically within
code No.
the Docket for this rulemaking action. If
* * * * * * * * * *
THE EYE
no adverse comments are received in
Eye, orbit, and response to this action, no further
Diseases of the Eye adnexa ................ 6015
activity is contemplated. If EPA receives
* * * * * adverse comments, the direct final rule
* * * * * Eye, orbit, and will be withdrawn and all public
6000 ............ Choroidopathy, including uve- adnexa ................ 6014 comments received will be addressed in
itis, iritis, cyclitis, and cho- a subsequent final rule based on this
roiditis. * * * * * proposed rule. EPA will not institute a
6001 ............ Keratopathy. Post-chiasmal disorders ....... 6046 second comment period. Any parties
6002 ............ Scleritis.
6006 ............ Retinopathy or maculopathy interested in commenting on this action
* * * * * should do so at this time.
not otherwise specified. Retinal dystrophy (including
6007 ............ Intraocular hemorrhage. retinitis pigmentosa) .......... 6042 DATES: Comments must be received in
6008 ............ Detachment of retina. Retinopathy, diabetic ............ 6040 writing by July 9, 2015.
6009 ............ Unhealed eye injury. Retinopathy or maculopathy ADDRESSES: Submit your comments,
6010 ............ Tuberculosis of eye. not otherwise specified ..... 6006 identified by Docket ID Number EPA–
6011 ............ Retinal scars, atrophy, or
irregularities. R03–OAR–2015–0311 by one of the
* * * * *
6012 ............ Angle-closure glaucoma. following methods:
6013 ............ Open-angle glaucoma. [FR Doc. 2015–13788 Filed 6–8–15; 8:45 am]
A. www.regulations.gov. Follow the
6014 ............ Malignant neoplasms of the on-line instructions for submitting
BILLING CODE 8320–01–P
eye, orbit, and adnexa (ex- comments.
cluding skin). B. Email: fernandez.cristina@epa.gov.
6015 ............ Benign neoplasms of the eye, C. Mail: EPA–R03–OAR–2015–0311,
orbit, and adnexa (excluding ENVIRONMENTAL PROTECTION Cristina Fernandez, Associate Director,
skin). AGENCY Office of Air Program Planning,
* * * * * 40 CFR Part 52 Mailcode 3AP30, U.S. Environmental
6025 ............ Disorders of the lacrimal appa- Protection Agency, Region III, 1650
ratus (epiphora, [EPA–R03–OAR–2015–0311; FRL–9928–67– Arch Street, Philadelphia, Pennsylvania
dacrocystitis, etc.) Region 3] 19103.
6026 ............ Optic neuropathy. D. Hand Delivery: At the previously-
6027 ............ Cataract. Approval and Promulgation of Air listed EPA Region III address. Such
Quality Implementation Plans; deliveries are only accepted during the
* * * * * Pennsylvania; 2011 Lead Base Year Docket’s normal hours of operation, and
6034 ............ Pterygium. Emissions Inventory special arrangements should be made
6035 ............ Keratoconus.
6036 ............ Status post corneal transplant. AGENCY: Environmental Protection for deliveries of boxed information.
Agency (EPA). Instructions: Direct your comments to
* * * * * ACTION: Proposed rule. Docket ID No. EPA–R03–OAR–2015–
6040 ............ Diabetic retinopathy. 0311. EPA’s policy is that all comments
6042 ............ Retinal dystrophy (including SUMMARY: The Environmental Protection received will be included in the public
retinitis pigmentosa). Agency (EPA) proposes to approve the docket without change, and may be
6046 ............ Post-chiasmal disorders. State Implementation Plan (SIP) made available online at
revision submitted by the www.regulations.gov, including any
* * * * * Commonwealth of Pennsylvania personal information provided, unless
regarding the 2011 lead base year the comment includes information
■ 7. In Appendix C to Part 4, revise the emissions inventory. The base year claimed to be Confidential Business
disability entries for diagnostic codes emissions inventory SIP revision was Information (CBI) or other information
6006, 6014, and 6015, and add disability submitted to meet the requirements of whose disclosure is restricted by statute.
entries for Retinopathy, diabetic; Retinal the Clean Air Act (CAA) for the Lyons Do not submit information that you
dystrophy (including retinitis 2008 lead National Ambient Air Quality consider to be CBI or otherwise
pigmentosa); and Post-chiasmal Standards (NAAQS) nonattainment area protected through www.regulations.gov
disorders to read as follows: (hereafter referred to as the ‘‘Lyons or email. The www.regulations.gov Web
Area’’ or ‘‘Area’’). In the Rules and site is an ‘‘anonymous access’’ system,
APPENDIX C TO PART 4— Regulations section of this Federal which means EPA will not know your
ALPHABETICAL INDEX OF DISABILITIES Register, EPA is approving the identity or contact information unless
Commonwealth’s SIP submittal as a
tkelley on DSK3SPTVN1PROD with PROPOSALS

you provide it in the body of your
Diagnostic direct final rule without prior proposal comment. If you send an email
code No. because the Agency views this as a comment directly to EPA without going
noncontroversial submittal and through www.regulations.gov, your
* * * * * anticipates no adverse comments. A email address will be automatically
New growths: more detailed description of the SIP captured and included as part of the
Benign submittal and EPA’s evaluation is comment that is placed in the public
included in a Technical Support docket and made available on the

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Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Proposed Rules
Action		Proposed rule.
Dates		Comments must be received on or before August 10, 2015.
Contact		Nick Olmos-Lau, M.D., Medical Officer, Part 4 VASRD Staff (211C), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 461-9700. (This is not a toll-free telephone number.)
FR Citation		80 FR 32513
RIN Number		2900-AP14
CFR Associated		Disability Benefits; Pensions and Veterans