80 FR 39011 - Schedule for Rating Disabilities-The Endocrine System

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 80, Issue 130 (July 8, 2015)

Page Range		39011-39020
FR Document		2015-16666

The Department of Veterans Affairs (VA) proposes to revise the portion of the VA Schedule for Rating Disabilities (Rating Schedule) that addresses the endocrine system. The intended effects of these changes are to update medical terminology, add medical conditions not currently in the Rating Schedule, revise the criteria to reflect medical advances since the last revision in 1996, and clarify the criteria.

Federal Register, Volume 80 Issue 130 (Wednesday, July 8, 2015)

[Federal Register Volume 80, Number 130 (Wednesday, July 8, 2015)]
[Proposed Rules]
[Pages 39011-39020]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2015-16666]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AO44

Schedule for Rating Disabilities--The Endocrine System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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[[Page 39012]]

SUMMARY: The Department of Veterans Affairs (VA) proposes to revise the
portion of the VA Schedule for Rating Disabilities (Rating Schedule)
that addresses the endocrine system. The intended effects of these
changes are to update medical terminology, add medical conditions not
currently in the Rating Schedule, revise the criteria to reflect
medical advances since the last revision in 1996, and clarify the
criteria.

DATES: Comments must be received by VA on or before September 8, 2015.

ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to the Director,
Regulations 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-AO44-Schedule for Rating Disabilities--The
Endocrine System.'' 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., FAAN, Medical
Officer, Compensation Service, Veterans Benefits Administration,
Department of Veterans Affairs, (211C) 810 Vermont Avenue NW.,
Washington, DC 20420, (202) 461-9700. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: As part of the ongoing revision of the VA
Schedule for Rating Disabilities (``Rating Schedule''), VA is proposing
changes to 38 CFR 4.119, Schedule of ratings-endocrine system. This
section was last updated in 1996. The endocrine system is made up of
multiple hormone-producing glands. Hormones are chemical messengers
that control the function of many body processes. While the actual
dysfunction occurs at the site of the gland, the signs and symptoms
manifest in the body systems on which the specific hormones act. For
diagnosis and acute management of endocrine diseases, medical
professionals focus on addressing the problem within the endocrine
system. However, the residual effects of an endocrine disease may
manifest within multiple body systems. Therefore, in general, VA
proposes specific criteria for the initial rating of endocrine diseases
within Sec. 4.119 to account for the unique functional impairments
associated with attempts to bring the condition under control. Once the
condition is effectively managed or has reached maximal medical
outcome, VA proposes to evaluate for the residual effects of disease
within the appropriate (adversely impacted) body system. For rating
clarity, the most commonly impacted systems would be referenced within
the specific diagnostic code (DC). By the revisions discussed herein,
VA aims to update medical terminology, add medical conditions not
currently in the Rating Schedule, revise the criteria to reflect
medical advances, and clarify the criteria.
In preparing this proposed revision, VA conducted a mini-summit in
Washington, DC, on December 2, 2009. VA also researched current medical
information and consulted with Veterans Health Administration (VHA)
subject matter experts.

DC 7900: Hyperthyroidism, Including, But Not Limited to, Graves'
Disease

VA proposes to update the title of DC 7900. Currently, this DC is
titled ``Hyperthyroidism.'' The most common cause of hyperthyroidism is
Graves' disease, an autoimmune disease that affects multiple organ
systems, including the eyes and skin. ``Hyperthyroidism (overactive
thyroid),'' Mayo Clinic, http://www.mayoclinic.com/health/hyperthyroidism/DS00344/DSECTION =causes. Given the prevalence of
hyperthyroidism due to Graves' Disease, VA proposes to explicitly
recognize Graves' disease under this DC by changing the title of DC
7900 from ``Hyperthyroidism'' to ``Hyperthyroidism, including, but not
limited to, Graves' disease.'' This is not a substantive change, but
simply an effort to increase rating efficiency. To account for less
common causes of hyperthyroidism not addressed by other DCs, VA does
not propose to limit this DC so that it is only applicable to Graves'
disease.
Hyperthyroidism refers to the excess synthesis or secretion of
thyroid hormone. Regardless of the specific cause, the symptoms
directly caused by excess thyroid hormone are the same. Therefore, VA
proposes to evaluate the disability associated with excess thyroid
hormone using a single set of rating criteria that reflects an earlier
diagnosis and current treatment options. Medical advances have
facilitated earlier diagnosis and treatment of hyperthyroidism.
Treatment is directed at symptom relief and includes antithyroid
medications, radioactive iodine therapy, and thyroidectomy (surgical
removal of the thyroid gland). Earlier treatment has decreased the
duration and severity of both acute and chronic symptoms of
hyperthyroidism, as well as its disabling residual effects. Therefore,
the existing evaluations of 100 and 60 percent for this condition are
no longer appropriate and VA proposes to no longer assign them.
In the majority of cases, by the time patients present with the
symptoms currently reflected in the criteria for a 30 percent
evaluation (tachycardia, tremor, and increased blood pressure or pulse
pressure), treatment is initiated. With treatment, these symptoms
generally resolve completely within three to six months. Therefore, VA
proposes to evaluate hyperthyroidism at 30 percent for six months after
initial diagnosis. Because symptoms generally resolve completely while
the 30 percent evaluation is applicable, VA also proposes to no longer
assign a 10 percent evaluation. To account for symptoms that do not
resolve completely within six months, VA proposes adding a directive
instructing VA personnel to ``rate residuals of disease or
complications of medical treatment . . . within the appropriate body
system.''
Since cardiovascular abnormalities are common in hyperthyroidism,
and some persist despite treatment with antithyroid medications, VA
proposes an alternative to the current approach which rates certain
cardiovascular manifestations within DC 7900 but refers VA personnel to
DC 7008 (hyperthyroid heart disease) if heart disease is the
predominant disability (see current Note (1)). Hyperthyroidism is
associated with a variety of cardiovascular problems including
tachycardia, systolic hypertension, cardiac arrhythmias particularly
atrial fibrillation, supraventricular tachycardia, congestive heart
failure or angina among others. See Faizel Osman et al.,
``Cardiovascular manifestations of hyperthyroidism before and after
antithyroid therapy,'' 49 (1) J. Am. College of Cardiology, 71-81
(2007). In order to address more specifically cardiovascular issues
related to hyperthyroidism, VA proposes to modify the existing Note (1)
to state that if cardiovascular or cardiac problems related to
hyperthyroidism are present separately evaluate under DC 7008.
In order to clarify a potentially confusing element in DC 7008 that
directs hyperthyroid heart disease to be part of the overall evaluation
of hyperthyroidism under DC 7900, VA

[[Page 39013]]

proposes to amend DC 7008 by directing that hyperthyroid heart disease
be rated under the appropriate cardiovascular diagnostic code,
depending on particular findings.
Currently, DC 7008 states that only when atrial fibrillation is
present hyperthyroidism may be evaluated either under DC 7900 or under
7010 (supraventricular arrhythmia), whichever results in a higher
evaluation. As described above, the potential cardiovascular conditions
related to hyperthyroidism are numerous and complex, and the current
approach limits the alternatives and precludes optimal assessment in
instances other than for atrial fibrillation.
Currently, Note (2) of DC 7900 states: ``If ophthalmopathy is the
sole finding, evaluate as field vision, impairment of (DC 6080);
diplopia (DC 6090); or impairment of central visual acuity (DC 6061-
6079).'' In the case of Graves' disease, which is evaluated under
proposed DC 7900, eye abnormalities can occur independently and in the
absence of hyperthyroidism. As such, it is not appropriate to limit
evaluation of such manifestations under either DC 7900 or an
appropriate DC within the eye body system. VA therefore proposes to
revise current Note (2) to read: Separately evaluate eye involvement
occurring as a manifestation of Graves' Disease as diplopia (DC 6090);
impairment of central visual acuity (DCs 6061-6066); or under the most
appropriate DCs in Sec. 4.79.

DC 7901: Thyroid Enlargement, Toxic

VA proposes to update the title of DC 7901 from ``Thyroid gland,
toxic adenoma of'' to ``Thyroid enlargement, toxic.'' When discussing
thyroid enlargement, ``toxic'' is the term used by the medical
community to indicate overactive thyroid function, also known as
hyperthyroidism. Currently, the rating criteria accompanying this DC
are identical to that accompanying current DC 7900. Therefore, rather
than repeating the criteria for hyperthyroidism, VA proposes Note (1)
to direct raters to evaluate toxic thyroid enlargement under proposed
DC 7900 (hyperthyroidism, including, but not limited to, Graves'
disease).
An enlarged thyroid may cause a visible swelling at the base of the
neck or thyroidectomy may result in disfigurement. To account for such
disfigurement, VA proposes Note (2) directing VA personnel: If
disfigurement of the neck is present due to thyroid disease or
enlargement, separately evaluate under DC 7800 (burn scar(s) of the
head, face, or neck; scar(s) of the head, face, or neck due to other
causes; or other disfigurement of the head, face, or neck).

DC 7902: Thyroid Enlargement, nontoxic

VA proposes to change the current title of DC 7902, ``Thyroid
gland, nontoxic adenoma of,'' to ``Thyroid enlargement, nontoxic.'' In
the context of thyroid function, ``nontoxic'' means that thyroid
function is normal.
Because thyroid function is normal, the disabling effects of
nontoxic thyroid enlargement are a result of disfigurement or pressure
on adjacent organs. A person with this condition may experience one or
both of these effects. However, under the current criteria an
evaluation may only be assigned for the more disabling effect.
Therefore, to better reflect the full impact of the condition, VA
proposes to amend the existing criteria to account for both effects
occurring simultaneously.
When the enlarged thyroid gland compresses adjacent organs, it may
produce symptoms due to pressure on anterior neck structures, including
the trachea (wheezing, cough), the esophagus (dysphagia), and the
recurrent laryngeal nerve (hoarseness). The severity of disabilities
related to pressure on adjacent organs is best evaluated under the
DC(s) within the appropriate body system. Therefore, VA proposes to
edit the current note under DC 7902, which would be proposed Note (1),
to clarify VA's intention to evaluate the symptoms due to pressure on
adjacent organs under the appropriate diagnostic code within the
appropriate body system and to delete the current phrase ``if doing so
would result in a higher evaluation than using this [DC].'' Currently,
DC 7902 provides a 20 percent evaluation when there is disfigurement of
the head or neck and a 0 percent evaluation when there is no such
disfigurement. Disfigurement due to an enlarged thyroid gland is not
defined in the existing criteria and, therefore, is subject to
individual interpretation. Objective criteria for evaluating
disfigurement of the neck already exist under DC 7800 (burn scar(s) of
the head, face, or neck; scar(s) of the head, face, or neck due to
other causes; or other disfigurement of the head, face, or neck).
Because this set of criteria covers all types of disfigurement of the
neck and provides a wider range of disability compensation, VA proposes
deletion of the current criteria and addition of proposed Note (2)
stating that disfigurement of the neck related to nontoxic thyroid
enlargement should be evaluated under DC 7800.
The proposed notes read as follows: ``Note (1): Evaluate symptoms
due to pressure on adjacent organs (such as the trachea, larynx, or
esophagus) under the appropriate diagnostic code(s) within the
appropriate body system.'' ``Note (2): If disfigurement of the neck is
present due to thyroid disease or enlargement, separately evaluate
under DC 7800 (burn scar(s) of the head, face, or neck; scar(s) of the
head, face, or neck due to other causes; or other disfigurement of the
head, face, or neck).''

DC 7903: Hypothyroidism

Hypothyroidism is currently evaluated at levels of 100, 60, 30, and
10 percent. Severe hypothyroidism is characterized by myxedema (coma or
crisis), a life-threatening form of hypothyroidism found predominantly
in undiagnosed or undertreated individuals that requires inpatient
hospitalization for stabilization. Medical advances in the diagnosis
and treatment of hypothyroidism have decreased the incidence of
myxedema to the point that myxedema coma occurs in only 0.1 percent of
all cases of hypothyroidism. Erik D Schraga, MD, ``Hypothyroidism and
Myxedema Coma in Emergency Medicine,'' Medscape Reference (Mar. 29,
2012), http://emedicine.medscape.com/article/768053-overview. Symptoms
of myxedema are currently evaluated at 100 and 60 percent. However,
given the severity of the condition, a 60 percent evaluation is
insufficient. Therefore, VA proposes a 100 percent evaluation for all
instances of hypothyroidism with myxedema. VA proposes to add a note to
provide: ``This evaluation shall continue for six months beyond the
date that an examining physician has determined crisis stabilization.
Thereafter, the residual effects of hypothyroidism shall be rated under
the appropriate diagnostic code(s) within the appropriate body
system(s) (e.g., eye, digestive, and mental disorders).''
Medical management of hypothyroidism, in the absence of myxedema,
results in improvement of laboratory values within a few weeks.
However, alleviation of other clinical symptoms may take up to six
months to resolve. See Bijay Vaidya, ``Management of Hypthyroidism,''
BMJ 337:a801 (2008). Therefore, VA proposes to evaluate hypothyroidism
in the absence of myxedema at 30 percent for six months after initial
diagnosis and would explain this in a note that would also provide
that, thereafter, the residual effects of hypothyroidism shall be rated
under the most appropriate diagnostic code(s) within the appropriate
body

[[Page 39014]]

system(s) (e.g., eye, digestive, and mental disorders).
VA also proposes to add a note to provide that eye involvement
associated with hypothyroidism would also be evaluated under Sec.
4.79. Specifically, the proposed note reads: ``If eye involvement, such
as exophthalmos, corneal ulcer, blurred vision, or diplopia, is also
present due to thyroid disease, also separately evaluate under
appropriate diagnostic code(s) in Sec. 4.79, Schedule of Ratings--Eye
(such as diplopia (DC 6090) or impairment of central visual acuity (DCs
6061-6066)).''

DC 7904: Hyperparathyroidism

Hyperparathyroidism, DC 7904, is currently evaluated at levels of
100, 60, and 10 percent. Due to increased routine laboratory testing,
hyperparathyroidism is usually diagnosed before patients develop severe
disease and often before any signs or symptoms, such as kidney stones,
gastrointestinal problems or weakness, are present. John I. Lew,
``Surgical Management of Primary Hyperparathyroidism: State of the
Art,'' 89 Surgical Clinics of N. Am. 1205-25 (2009);
``Hyperparathyroidism,'' Mayo Clinic, http://www.mayoclinic.com/health/hyperparathyroidism/DS00396. Therefore, the existing criteria for
evaluations at the 100 and 60 percent rating are no longer appropriate,
and VA proposes revision of all the criteria consistent with medical
advances.
Individuals diagnosed with hyperparathyroidism, but without
symptoms (asymptomatic), require annual monitoring of their serum
calcium levels and creatinine clearance (renal function). Bone density
monitoring is also required every one to two years. These tests help
medical professionals monitor the progression of the disease and to
determine when surgery is necessary. Therefore, VA proposes to evaluate
asymptomatic hyperparathyroidism at 0 percent.
Individuals with mild hyperparathyroidism may develop symptoms of
hypercalcemia before surgery is determined to be necessary. Even after
surgery, mild symptoms may persist. Therefore, VA proposes a 10 percent
evaluation for the presence of symptoms, such as fatigue, anorexia,
nausea, or constipation, despite surgery or in subjects deemed not to
be candidates for surgery who require continuous medications for
control.
Potential complications of hyperparathyroidism include gastric
ulcers, kidney stones, decrease kidney function, and decreased bone
mass associated with fragility fractures. Early intervention through
laboratory monitoring generally prevents these complications. An
increase in serum calcium, decreases in creatinine clearance, and
decreases in bone density are used as laboratory indicators for the
worsening of disease and evaluation for surgical intervention.
Therefore, VA proposes a 60 percent evaluation for hypercalcemia
indicated by at least one of the following: Total Ca greater than 12mg/
dL (3-3.5 mmol/L), Ionized Ca greater than 5.6 mg/dL (2-2.5 mmol/L),
creatinine clearance less than 60 mL/min, bone mineral density T-score
less than 2.5 (SD below mean) at any site or previous fragility
fracture). Because these findings indicate that surgical or
pharmacologic intervention is warranted and such intervention usually
resolves symptoms, VA proposes that the 60 percent evaluation shall
continue until such intervention occurs. If surgery is not indicated,
the 60 percent evaluation would continue for 6 months after
pharmacological treatment begins. After six months, rating would be
based on residuals under the appropriate diagnostic code(s) within the
appropriate body system based on examination.
Parathyroidectomy is the treatment of choice for symptomatic
hyperparathyroidism. Therefore, VA proposes a 100 percent evaluation
for six months after surgical intervention for hyperparathyroidism and
thereafter, an evaluation based on the residuals of hyperparathyroidism
or medical treatment under the appropriate diagnostic code(s) within
the appropriate body system.
VA proposes to amend the current note under DC 7904 by numbering
the note as proposed Note (4) and clarifying that the residuals of
hyperparathyroidism are to be rated under the appropriate DC. The
current note reads: ``Following surgery or treatment, evaluate as
digestive, skeletal, renal, or cardiovascular residuals or as endocrine
dysfunction.'' The proposed Note (4) reads: ``Following surgery or
other treatment, evaluate chronic residuals, such as nephrolithiasis
(kidney stones), decreased renal function, fractures, vision problems,
and cardiovascular complications, under the appropriate diagnostic
codes.''

DC 7905: Hypoparathyroidism

Parathyroid hormone controls the balance of calcium in the body.
When there is not enough of this hormone, the condition is known as
hypoparathyroidism. The predominant symptoms of hypoparathyroidism is
neuromuscular irritability, including, but not limited to, paresthesias
(tingling and numbness involving fingertips, toes, or perioral area),
hyperirritability, fatigue, anxiety, mood swings and/or personality
disturbances, seizures, hoarseness (due to laryngospasm), wheezing and
dyspnea (due to bronchospasm), muscle cramps, and electrolyte
imbalances (hypomagnesemia, hypokalemia, and alkalosis).
Currently, evaluations are assigned based on some of these
symptoms. However, because many of the symptoms of parathyroid hormone
deficiency are caused by an imbalance of calcium in the body (decreased
extracellular ionized calcium levels and hypocalcemia), when
hypoparathyroidism is treated with calcium and vitamin D
supplementation, the symptoms are generally eliminated. Paul
Fitzgerald, ``Chapter 26. Endocrine Disorders'' (2014), http://accessmedicine.mhmedical.com/content.aspx?bookid=330&Sectionid=44291028. Therefore, VA proposes new
evaluation criteria that account for this treatment. Specifically, VA
proposes a 100 percent evaluation for three months after initial
diagnosis and, thereafter, to rate residual effects, such as
nephrolithiasis (kidney stones), cataracts, decreased renal function,
and congestive heart failure under the appropriate DCs.

New DC 7906: Thyroiditis

VA proposes to add a new DC for thyroiditis, which is inflammation
of the thyroid gland. The condition most often results from an
autoimmune disease (known as Hashimoto's thyroiditis), where the immune
system attacks the thyroid gland.
However, regardless of the specific cause, thyroiditis may manifest
as hyperthyroidism, hypothyroidism, or with no change in thyroid
function. Because hyperthyroidism and hypothyroidism would be addressed
in the Rating Schedule as proposed DCs 7900 and 7903, respectively, VA
proposes a note to clarify that these manifestations be rated under
those DCs.
While thyroiditis may also be present in a person with normal
thyroid function, because thyroiditis increases the likelihood of
developing hyperthyroidism or hypothyroidism, the thyroid function of
these individuals must be monitored. This factor is not currently
accounted for in the Rating Schedule. Therefore, for these individuals,
VA proposes that a 0 percent evaluation for asymptomatic thyroiditis be
associated with this DC.

[[Page 39015]]

DC 7907: Cushing's Syndrome

Cushing's syndrome is the result of prolonged elevation in the
amount of glucocorticoid in the body. The severity of the signs and
symptoms is determined by the duration and level of glucocorticoid
exposure.
Currently, evaluations for Cushing's syndrome are assigned based in
part on enlargement of the adrenal gland (which produces these
hormones) and the pituitary gland (which produces hormones that trigger
the adrenal gland). However, glandular enlargement is not indicative of
disease severity. Exogenous glucocorticoid exposure (the intake of
glucocorticoids), the most common cause of Cushing's syndrome, does not
involve enlargement of the pituitary or adrenal glands. Therefore, VA
proposes to delete the requirement for the presence of enlargement of
the pituitary or adrenal gland as one of the criteria required for 100
and 60 percent evaluations.
The muscle weakness associated with Cushing's syndrome is a result
of proximal muscle wasting and weakness caused by excess glucocorticoid
hormones. This muscle wasting results in the inability to rise from a
squatting position without assistance, and, in more severe cases, the
inability to climb stairs or get up from a deep chair. Lynnette K.
Nieman, MD, ``Epidemiology and clinical manifestations of Cushing's
syndrome'' UpToDate (Oct. 22, 2013), http://www.uptodate.com/contents/epidemiology-and-clinical-manifestations-of-cushings-syndrome. To
clarify the criteria for 100 and 60 percent evaluations, VA proposes to
replace ``loss of muscle strength'' with the more specific criteria of
``proximal upper and lower extremity muscle wasting that results in
inability to rise from squatting position, climb stairs, rise from a
deep chair without assistance, or raise arms.'' VA also proposes to
remove ``weakness'' from the list of criteria for a 100 percent
evaluation because it is already captured with language replacing
``loss of muscle strength.'' With these proposed modifications, a 100
percent evaluation would be assigned for Cushing's syndrome if there is
``active, progressive disease, including areas of osteoporosis,
hypertension, and proximal upper and lower extremity muscle wasting
that results in inability to rise from a squatting position, climb
stairs, rise from a deep chair without assistance, or raise arms.''
Similarly, VA proposes a 60 percent evaluation for Cushing's syndrome
if there is ``[p]roximal upper or lower extremity muscle wasting that
results in inability to rise from a squatting position, climb stairs,
rise from a deep chair without assistance, or raise arms.'' VA proposes
no change to the current 30 percent evaluation criteria.
The treatment for Cushing's syndrome is determined by the
glucocorticoid source. Endogenous hypercortisolism (overproduction of
glucocorticoid hormones by the adrenal gland) is treated by surgical
removal of the adrenal gland, medical adrenalectomy, surgical resection
of a pituitary tumor, or radiation therapy of the pituitary gland.
Exogenous hypercortisolism is treated via gradual reduction of the
outside source, such as corticosteroid medications. Because early
medical intervention has decreased the complications associated with
Cushing's syndrome, VA proposes evaluations for Cushing's syndrome at
the 100, 60, or 30 percent level for six months after initial
diagnosis. Because treatment may not completely eliminated
complications or may itself be associated with complications, after six
months, VA proposes to rate residuals such as adrenal insufficiency,
cardiovascular, psychiatric, skin, or skeletal complications under the
appropriate diagnostic code(s) within the appropriate body system.
Therefore, VA proposes to amend the note following DC 7907 to reflect
the above proposed changes.

DC 7908: Acromegaly

Acromegaly, DC 7908, is a condition in which the pituitary gland
produces excess growth hormone, usually due to a benign tumor. The
excessive amount of hormone results in enlargement of various body
tissues, including bone. Acromegaly is currently evaluated at levels of
100, 60, and 30 percent. VA proposes no changes in the evaluation
criteria for the 100 and 60 percent levels. The current 30 percent
evaluation criteria for acromegaly require that there be enlargement of
acral parts or overgrowth of long bones, and an enlarged sella turcica
(the depression at the base of the skull where the pituitary gland is
located). VA proposes to remove ``enlarged sella turcica'' as one of
the required criteria. Although acromegaly is generally due to a
pituitary tumor (which commonly results in enlargement of the sella
turcica), it occasionally arises from causes that do not produce an
enlarged sella turcica. Further, enlargement of the sella turcica is
not an indicator of the severity of the condition. Therefore, it is not
appropriate to retain ``enlarged sella turcica'' as a required
criterion, and VA proposes to remove it.

DC 7909: Diabetes Insipidus

Inadequate secretion of or a resistance to antidiuretic hormone
(ADH) is the cause of diabetes insipidus (DI). ADH limits the amount of
water that the kidneys allow to leave the body. A lack of or resistance
to ADH causes excessive excretion of free water. This disease is
characterized by polyuria (frequent urination), polydipsia (excessive
thirst), and nocturia (frequent night time urination). Without
treatment, dehydration and bladder enlargement commonly result. If
treated, diabetes insipidus does not cause severe problems or a
reduction in life expectancy. See Goldman's Cecil Medicine Chapter 232
(24th ed. 2011). The prognosis for this disease is excellent, because
it is frequently transient and there are excellent medications with
different means of administration to treat the condition on a chronic
basis if this condition becomes permanent. Most individuals, even in
emergency situations, can replace urine loss with increased fluid
intake. Therefore, the reliance in the current criteria on the need for
parenteral (IV) hydration is no longer appropriate, and VA proposes
deletion of the current criteria.
In its place, in order to allow the condition to become stabilized
and to determine if the condition is transient or becoming permanent,
VA proposes a 30 percent evaluation for three months after the initial
diagnosis. Once the condition is stabilized, the need for long term
medication can be assessed. Many patients are able to control their
condition with oral or trans-nasal medication, while others require
parenteral treatment (when oral or trans-nasal medications are either
not tolerable or effective). Therefore, VA proposes a reevaluation of
diabetes insipidus after the three month period. If DI has subsided, VA
would rate any residuals under the appropriate diagnostic code(s)
within the appropriate body system. For those DI cases with persistent
polyuria or requiring continuous hormonal therapy, VA proposes a 10
percent rating.

DC 7911: Addison's Disease (Adrenocortical Insufficiency)

The medical community has shifted from the term ``adrenal cortical
hypofunction'' to the term ``adrenocortical insufficiency.'' Therefore,
for clarity and consistency with current medical terminology, VA
proposes to retitle this DC ``Addison's disease (adrenocortical
insufficiency).'' VA does not propose changes to the

[[Page 39016]]

rating criteria and notes associated with this DC.

DC 7912: Polyglandular Syndrome (Multiple Endocrine Neoplasia,
Autoimmune Polyglandular Syndrome)

``Pluriglandular syndrome'' refers, not to a single condition, but
to a group of conditions that impact multiple glands in the body.
Therefore, a person is likely to be given a more specific diagnosis,
rather than one with this general term. Therefore, VA proposes to
include the most common forms of the condition in the title of the DC.
Also, over time, the medical community has shifted from the term
``pluriglandular'' to ``polyglandular'' when referring to this
condition. Therefore, to better reflect the terminology currently
associated with the condition, VA proposes to update the title of DC
7912 to ``Polyglandular syndrome (multiple endocrine neoplasia,
autoimmune polyglandular syndrome).'' The current guidance for
evaluation is to evaluate according to major manifestations. VA
proposes to revise the guidance to include some of the common
manifestations of the syndrome. The proposed guidance reads: ``Evaluate
according to major manifestations to include, but not limited to, Type
I diabetes mellitus, hyperthyroidism, hypothyroidism,
hypoparathyroidism, or Addison's disease.''

DC 7913: Diabetes Mellitus

Diabetes mellitus is a complex condition that impacts individuals
in a variety of ways. At this time, VA proposes only one clarifying
amendment to this DC. VA proposes to clarify that the rating criteria
for a 20, 40, or 60 percent rating require ``one or more daily
injection'' of insulin. This clarifying amendment is not a substantive
change but rather a clarification of VA's interpretation of this DC
that an injection of insulin is required to achieve a 20, 40, 60, or
100 percent rating. To ensure that the full range of relevant factors
is adequately addressed, VA is not proposing to amend the remaining
rating criteria pertaining to this DC at this time. Rather, VA intends
to establish a work group to specifically address this condition. Upon
consideration of the work group's findings, VA will determine whether
amendments to the remaining existing criteria are necessary and such
amendments, if any, will be addressed in a future proposal.

DC 7914: Neoplasm, Malignant, Any Specified Part of the Endocrine
System

VA proposes no changes at this time.

DC 7915: Neoplasm, Benign, Any Specified Part of the Endocrine System

VA proposes to retain the existing direction to rate this condition
based on residuals of endocrine dysfunction, but separate the rating
direction from the title of DC 7915.

DC 7916: Hyperpituitarism (Prolactin Secreting Pituitary Dysfunction)

The existing note regarding the evaluation of this condition also
applies to DCs 7917 and 7918 and is given after DC 7918. Therefore, it
can be overlooked with regard to the other DCs. Therefore, VA proposes
to include the same note regarding the evaluation of each condition
directly under each DC and to amend the current note to reflect the
proposed change. The conditions would all continue to be evaluated as
malignant or benign neoplasm, as appropriate, so no substantive change
is being made.

DC 7917: Hyperaldosteronism (Benign or Malignant)

See discussion of DC 7916.

DC 7918: Pheochromocytoma (Benign or Malignant)

See discussion of DC 7916.

DC 7919: C-cell Hyperplasia of the Thyroid

Currently, this condition is rated in the same way as a malignant
neoplasm. However, this does not adequately address all potential
manifestations of this condition. Therefore, VA proposes to replace the
existing note with one that provides as follows: ``If antineoplastic
therapy is required, evaluate as a malignant neoplasm under DC 7914. If
a prophylactic thyroidectomy is performed (based upon genetic testing)
and antineoplastic therapy is not required, evaluate as hypothyroidism
under DC 7903.'' These changes are in keeping with current medical
information about C-cell hyperplasia.

Technical Amendments

VA also proposes several technical amendments. We would add a
citation reference to 38 U.S.C. 1155 at the end of Sec. 4.119, and we
would update Appendix A, B, and C of part 4 to reflect the above noted
proposed amendments.

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).

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 directly affect only
individuals and would not directly affect small entities. Therefore,
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial
and final regulatory flexibility analysis requirements of sections 603
and 604.

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 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'' requiring review by the Office of
Management and Budget (OMB), unless OMB waives such review, 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 the Executive Order.''
The economic, interagency, budgetary, legal, and policy
implications of this regulatory action have been examined, and it has
been determined to be a significant regulatory action under Executive
Order 12866 because it is likely to result in a rule that may raise
novel policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order. VA's
impact

[[Page 39017]]

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.''

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.

Catalog of Federal Domestic Assistance

The Catalog of Federal Domestic Assistance numbers and titles for
the programs affected by this document are 64.104, Pension for Non-
Service-Connected Disability for Veterans, and 64.109, Veterans
Compensation for Service-Connected Disability.

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 L.
Nabors, II, Chief of Staff, approved this document on June 30, 2015,
for publication.

List of Subjects in 38 CFR Part 4

Disability benefits, Pensions, Veterans.

Dated: July 1, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management, Office of
the General Counsel, Department of Veterans Affairs.

For the reasons set out in the preamble, the Department of Veterans
Affairs proposes to amend 38 CFR part 4 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. 4.104 by revising the entry for 7008 to read as follows:

Sec. 4.104 Schedule of ratings--cardiovascular system.

Diseases of the Heart
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------

* * * * *
7008 Hyperthyroid heart disease.
Rate under the appropriate
cardiovascular diagnostic code,
depending on particular findings.

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

0
3. Section 4.119 is revised to read as follows:

The Endocrine System

Sec. 4.119 Schedule of ratings--endocrine system.

------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7900 Hyperthyroidism, including, but not limited to,
Graves' disease:
For six months after initial diagnosis.............. 30
Thereafter, rate residuals of disease or
complications of medical treatment within the
appropriate diagnostic code(s) within the
appropriate body system.
Note (1): If hyperthyroid cardiovascular or cardiac
disease is present, separately evaluate under DC
7008 (hyperthyroid heart disease).
Note (2): Separately evaluate eye involvement
occurring as a manifestation of Graves' Disease as
diplopia (DC 6090); impairment of central visual
acuity (DCs 6061-6066); or under the most
appropriate DCs in Sec. 4.79.
7901 Thyroid enlargement, toxic.
Note (1): Evaluate symptoms of hyperthyroidism under
DC 7900, hyperthyroidism, including, but not
limited to, Graves' disease.
Note (2): If disfigurement of the neck is present
due to thyroid disease or enlargement, separately
evaluate under DC 7800 (burn scar(s) of the head,
face, or neck; scar(s) of the head, face, or neck
due to other causes; or other disfigurement of the
head, face, or neck).
7902 Thyroid enlargement, nontoxic:
Note (1): Evaluate symptoms due to pressure on
adjacent organs (such as the trachea, larynx, or
esophagus) under the appropriate diagnostic code(s)
within the appropriate body system.
Note (2): If disfigurement of the neck is present
due to thyroid disease or enlargement, separately
evaluate under DC 7800 (burn scar(s) of the head,
face, or neck; scar(s) of the head, face, or neck
due to other causes; or other disfigurement of the
head, face, or neck).
7903 Hypothyroidism:
Hypothyroidism manifesting as myxedema (cold 100
intolerance, muscular weakness, cardiovascular
involvement (including, but not limited to
hypotension, bradycardia, and pericardial
effusion), and mental disturbance (including, but
not limited to dementia, slowing of thought and
depression)).......................................
Note (1): This evaluation shall continue for six
months beyond the date that an examining physician
has determined crisis stabilization. Thereafter,
the residual effects of hypothyroidism shall be
rated under the appropriate diagnostic code(s)
within the appropriate body system(s) (e.g., eye,
digestive, and mental disorders).
Hypothyroidism without myxedema..................... 30
Note (2): This evaluation shall continue for six
months after the initial diagnosis. Thereafter,
rate residuals of disease or medical treatment
under the most appropriate diagnostic code(s)under
the appropriate body system (e.g., eye, digestive,
mental disorders).
Note (3): If eye involvement, such as exophthalmos,
corneal ulcer, blurred vision, or diplopia, is also
present due to thyroid disease, also separately
evaluate under the appropriate diagnostic code(s)
in Sec. 4.79, Schedule of Ratings--Eye (such as
diplopia (DC 6090) or impairment of central visual
acuity (DCs 6061-6066)).

[[Page 39018]]

7904 Hyperparathyroidism
For six months from date of discharge following 100
surgery............................................
Note (1): After six months, rate on residuals under
the appropriate diagnostic code(s) within the
appropriate body system(s) based on a VA
examination.
Hypercalcemia (indicated by at least one of the 60
following: Total Ca greater than 12mg/dL (3-3.5
mmol/L), Ionized Ca greater than 5.6 mg/dL (2-2.5
mmol/L), creatinine clearance less than 60 mL/min,
bone mineral density T-score less than 2.5 SD
(below mean) at any site or previous fragility
fracture)
Note (2): Where surgical intervention is indicated,
this evaluation shall continue until the day of
surgery, at which time the provisions pertaining to
a 100 percent evaluation shall apply.
Note (3): Where surgical intervention is not
indicated, this evaluation shall continue for six
months after pharmacologic treatment begins. After
six months, rate on residuals under the appropriate
diagnostic code(s) within the appropriate body
system(s) based on a VA examination.
Symptoms such as fatigue, anorexia, nausea, or 10
constipation that occur despite surgery; or in
individuals who are not candidates for surgery but
require continuous medication for control..........
Asymptomatic........................................ 0
Note (4): Following surgery or other treatment,
evaluate chronic residuals, such as nephrolithiasis
(kidney stones), decreased renal function,
fractures, vision problems, and cardiovascular
complications, under the appropriate diagnostic
codes.
7905 Hypoparathyroidism:
For three months after initial diagnosis............ 100
Thereafter, evaluate chronic residuals, such as
nephrolithiasis (kidney stones), cataracts,
decreased renal function, and congestive heart
failure under the appropriate diagnostic codes.
7906 Thyroiditis
With normal thyroid function (euthyroid)............ 0
Note: Manifesting as hyperthyroidism, evaluate as
hyperthyroidism, including, but not limited to,
Graves' disease (DC 7900); manifesting as
hypothyroidism, evaluate as hypothyroidism (DC
7903).
7907 Cushing's syndrome:
As active, progressive disease, including areas of 100
osteoporosis, hypertension, and proximal upper and
lower extremity muscle wasting that results in
inability to rise from squatting position, climb
stairs, rise from a deep chair without assistance,
or raise arms......................................
Proximal upper or lower extremity muscle wasting 60
that results in inability to rise from squatting
position, climb stairs, rise from a deep chair
without assistance, or raise arms..................
With striae, obesity, moon face, glucose 30
intolerance, and vascular fragility................
Note: The evaluations specifically indicated under
this diagnostic code shall continue for six months
following initial diagnosis. After six months, rate
on residuals under the appropriate diagnostic
code(s) within the appropriate body system(s).
7908 Acromegaly:
Evidence of increased intracranial pressure (such as 100
visual field defect), arthropathy, glucose
intolerance, and either hypertension or
cardiomegaly.......................................
Arthropathy, glucose intolerance, and hypertension.. 60
Enlargement of acral parts or overgrowth of long 30
bones..............................................
7909 Diabetes insipidus:
For three months after initial diagnosis............ 30
Note: Thereafter, if Diabetes insipidus has
subsided, rate residuals under the appropriate
diagnostic code(s) within the appropriate body
system.
With persistent polyuria or requiring continuous 10
hormonal therapy...................................
7911 Addison's disease (adrenalcortical insufficiency):
Four or more crises during the past year............ 60
Three crises during the past year, or; five or more 40
episodes during the past year......................
One or two crises during the past year, or; two to 20
four episodes during the past year, or; weakness
and fatigability, or; corticosteroid therapy
required for control...............................
Note (1): An Addisonian ``crisis'' consists of the
rapid onset of peripheral vascular collapse (with
acute hypotension and shock), with findings that
may include: anorexia; nausea; vomiting;
dehydration; profound weakness; pain in abdomen,
legs, and back; fever; apathy, and depressed
mentation with possible progression to coma, renal
shutdown, and death.
Note (2): An Addisonian ``episode,'' for VA
purposes, is a less acute and less severe event
than an Addisonian crisis and may consist of
anorexia, nausea, vomiting, diarrhea, dehydration,
weakness, malaise, orthostatic hypotension, or
hypoglycemia, but no peripheral vascular collapse.
Note (3): Tuberculous Addison's disease will be
evaluated as active or inactive tuberculosis. If
inactive, these evaluations are not to be combined
with the graduated ratings of 50 percent or 30
percent for non-pulmonary tuberculosis specified
under Sec. 4.88b. Assign the higher rating.
7912 Polyglandular syndrome (multiple endocrine
neoplasia, autoimmune polyglandular syndrome):
Evaluate according to major manifestations to
include, but not limited to, Type I diabetes
mellitus, hyperthyroidism, hypothyroidism,
hypoparathyroidism, or Addison's disease.
7913 Diabetes mellitus
Requiring more than one daily injection of insulin, 100
restricted diet, and regulation of activities
(avoidance of strenuous occupational and
recreational activities) with episodes of
ketoacidosis or hypoglycemic reactions requiring at
least three hospitalizations per year or weekly
visits to a diabetic care provider, plus either
progressive loss of weight and strength or
complications that would be compensable if
separately evaluated...............................
Requiring one or more daily injection of insulin, 60
restricted diet, and regulation of activities with
episodes of ketoacidosis or hypoglycemic reactions
requiring one or two hospitalizations per year or
twice a month visits to a diabetic care provider,
plus complications that would not be compensable if
separately evaluated...............................
Requiring one or more daily injection of insulin, 40
restricted diet, and regulation of activities......
Requiring one or more daily injection of insulin and 20
restricted diet, or; oral hypoglycemic agent and
restricted diet....................................
Manageable by restricted diet only.................. 10

[[Page 39019]]

Note (1): Evaluate compensable complications of
diabetes separately unless they are part of the
criteria used to support a 100 percent evaluation.
Noncompensable complications are considered part of
the diabetic process under DC 7913.
Note (2): When diabetes mellitus has been
conclusively diagnosed, do not request a glucose
tolerance test solely for rating purposes.
7914 Neoplasm, malignant, any specified part of the 100
endocrine system
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.
7915 Neoplasm, benign, any specified part of the
endocrine system:
Rate as residuals of endocrine dysfunction.
7916 Hyperpituitarism (prolactin secreting pituitary
dysfunction):
Note: Evaluate as malignant or benign neoplasm, as
appropriate.
7917 Hyperaldosteronism (benign or malignant):
Note: Evaluate as malignant or benign neoplasm, as
appropriate.
7918 Pheochromocytoma (benign or malignant):
Note: Evaluate as malignant or benign neoplasm as
appropriate.
7919 C-cell hyperplasia of the thyroid:
If antineoplastic therapy is required, evaluate as a
malignant neoplasm under DC 7914. If a prophylactic
thyroidectomy is performed (based upon genetic
testing) and antineoplastic therapy is not
required, evaluate as hypothyroidism under DC 7903.
------------------------------------------------------------------------

(Authority: 38 U.S.C. 1155)
0
3. Amend appendix A to part 4 by revising the entries for Secs.
Sec. Sec. 4.104 and 4.119 to read as follows:

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

------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------

* * * * * * *
4.104............. 7000 Evaluation July 6, 1950; evaluation
September 22, 1978; evaluation January
12, 1998.

* * * * * * *
7008 Evaluation January 12, 1998; evaluation
[effective date of final rule].

* * * * * * *
4.119............. 7900 Criterion August 13, 1981; evaluation
June 9, 1996; title [effective date of
final rule]; evaluation [effective
date of final rule]; criterion
[effective date of final rule]; note
[effective date of final rule].
7901 Criterion August 13, 1981; evaluation
June 9, 1996; title [effective date of
final rule]; evaluation [effective
date of final rule]; criterion
[effective date of final rule].
7902 Evaluation August 13, 1981; criterion
June 9, 1996; title [effective date of
final rule]; evaluation [effective
date of final rule]; criterion
[effective date of final rule]; note
[effective date of final rule].
7903 Criterion August 13, 1981; evaluation
June 9, 1996; evaluation [effective
date of final rule]; criterion
[effective date of final rule]; note
[effective date of final rule].
7904 Criterion August 13, 1981; evaluation
June 9, 1996; evaluation [effective
date of final rule]; criterion
[effective date of final rule]; note
[effective date of final rule].
7905 Evaluation; August 13, 1981; evaluation
June 9, 1996; evaluation [effective
date of final rule]; criterion
[effective date of final rule]; note
[effective date of final rule]. Added
[effective date of final rule].
7906 Evaluation; August 13, 1981; evaluation
June 9, 1996; criterion [effective
date of final rule]; note [effective
date of final rule].
7907 Criterion August 13, 1981; criterion
June 9, 1996; criterion [effective
date of final rule].
7908 Evaluation August 13, 1981; criterion
June 9, 1996; evaluation June 9, 1996;
criterion [effective date of final
rule]; note [effective date of final
rule].
7909 Removed June 9, 1996.
7910 Evaluation March 11, 1969; evaluation
August 13, 1981; criterion June 9,
1996; title [effective date of final
rule].
7911 Title [effective date of final rule].
7912 Criterion September 9, 1975; criterion
August 13, 1981; criterion June 6,
1996; evaluation June 9, 1996;
criterion [effective date of final
rule].
7913 Criterion March 10, 1976; criterion
August 13, 1981; criterion June 9,
1996.
7914 Criterion June 9, 1996.
7915 Added June 9, 1996.
7916 Added June 9, 1996.
7917 Added June 9, 1996.
7918 Added June 9, 1996; evaluation June 9,
1996; criterion [effective date of
final rule].
7919 * * *

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

[[Page 39020]]

0
4. Amend Appendix B to Part 4 by revising the entries for diagnostic
codes 7900, 7901, 7902, 7911, and adding diagnostic code 7906 to read
as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------

* * * * * * *
------------------------------------------------------------------------
THE ENDOCRINE SYSTEM
------------------------------------------------------------------------
7900....................... Hyperthyroidism, including, but not limited
to, Graves' disease.
7901....................... Thyroid enlargement, toxic.
7902....................... Thyroid enlargement, nontoxic.

* * * * * * *
7906....................... Thyroiditis.

* * * * * * *
7911....................... Addison's disease (adrenocortical
insufficiency).
7912....................... Polyglandular syndrome (multiple endocrine
neoplasia, autoimmune polyglandular
syndrome).

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

0
4. Amend appendix C by:
0
a. Adding entries for Graves' disease. Polyglandular syndrome and
Thyroiditis in alphabetical order; and
0
b. Revising the disability entry for Thyroid gland. The additions and
revision read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
Diagnostic
code No.
------------------------------------------------------------------------

* * * * *
Graves' disease............................................ 7900

* * * * *
Polyglandular syndrome..................................... 7912

* * * * *

Thyroid gland
Nontoxic thyroid enlargement........................... 7902
Toxic thyroid enlargement.............................. 7901
Thyroiditis................................................ 7906

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

[FR Doc. 2015-16666 Filed 7-7-15; 8:45 am]
BILLING CODE 8320-01-P

$Federal Register / Vol. 80, No. 130 / Wednesday, July 8, 2015 / Proposed Rules 39019 Rating Note (1): Evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. Note (2): When diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. 7914 Neoplasm, malignant, any specified part of the endocrine system 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 § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residuals. 7915 Neoplasm, benign, any specified part of the endocrine system: Rate as residuals of endocrine dysfunction. 7916 Hyperpituitarism (prolactin secreting pituitary dysfunction): Note: Evaluate as malignant or benign neoplasm, as appropriate. 7917 Hyperaldosteronism (benign or malignant): Note: Evaluate as malignant or benign neoplasm, as appropriate. 7918 Pheochromocytoma (benign or malignant): Note: Evaluate as malignant or benign neoplasm as appropriate. 7919 C-cell hyperplasia of the thyroid: If antineoplastic therapy is required, evaluate as a malignant neoplasm under DC 7914. If a prophylactic thyroidectomy is performed (based upon genetic testing) and antineoplastic therapy is not required, evaluate as hypothyroidism under DC 7903. (Authority: 38 U.S.C. 1155) ■ 3. Amend appendix A to part 4 by Appendix A to Part 4—Table of revising the entries for Secs. §§ 4.104 Amendments and Effective Dates Since and 4.119 to read as follows: 1946 Diagnostic Sec. code No. * * * * * * * 4.104 7000 Evaluation July 6, 1950; evaluation September 22, 1978; evaluation January 12, 1998. * * * * * * * 7008 Evaluation January 12, 1998; evaluation [effective date of final rule]. * * * * * * * 4.119 7900 Criterion August 13, 1981; evaluation June 9, 1996; title [effective date of final rule]; evaluation [effective date of final rule]; criterion [effective date of final rule]; note [effective date of final rule]. 7901 Criterion August 13, 1981; evaluation June 9, 1996; title [effective date of final rule]; evaluation [effective date of final rule]; criterion [effective date of final rule]. 7902 Evaluation August 13, 1981; criterion June 9, 1996; title [effective date of final rule]; evaluation [effective date of final rule]; criterion [effective date of final rule]; note [effective date of final rule]. 7903 Criterion August 13, 1981; evaluation June 9, 1996; evaluation [effective date of final rule]; criterion [effective date of final rule]; note [effective date of final rule]. 7904 Criterion August 13, 1981; evaluation June 9, 1996; evaluation [effective date of final rule]; criterion [effective date of final rule]; note [effective date of final rule]. 7905 Evaluation; August 13, 1981; evaluation June 9, 1996; evaluation [effective date of final rule]; criterion [effective date of final rule]; note [effective date of final rule]. Added [effective date of final rule]. 7906 Evaluation; August 13, 1981; evaluation June 9, 1996; criterion [effective date of final rule]; note [effective date of final rule]. 7907 Criterion August 13, 1981; criterion June 9, 1996; criterion [effective date of final rule]. 7908 Evaluation August 13, 1981; criterion June 9, 1996; evaluation June 9, 1996; criterion [effective date of final rule]; note [effective date of final rule]. 7909 Removed June 9, 1996. 7910 Evaluation March 11, 1969; evaluation August 13, 1981; criterion June 9, 1996; title [effective date of final rule]. 7911 Title [effective date of final rule]. 7912 Criterion September 9, 1975; criterion August 13, 1981; criterion June 6, 1996; evaluation June 9, 1996; criterion [effective date of final rule]. 7913 Criterion March 10, 1976; criterion August 13, 1981; criterion June 9, 1996. srobinson on DSK5SPTVN1PROD with PROPOSALS 7914 Criterion June 9, 1996. 7915 Added June 9, 1996. 7916 Added June 9, 1996. 7917 Added June 9, 1996. 7918 Added June 9, 1996; evaluation June 9, 1996; criterion [effective date of final rule]. 7919 * * * * * * * * * * VerDate Sep<11>2014 19:55 Jul 07, 2015 Jkt 235001 PO 00000 Frm 00030 Fmt 4702 Sfmt 4702 E:\FR\FM\08JYP1.SGM 08JYP1$

39020 Federal Register / Vol. 80, No. 130 / Wednesday, July 8, 2015 / Proposed Rules

■ 4. Amend Appendix B to Part 4 by 7900, 7901, 7902, 7911, and adding Appendix B to Part 4—Numerical Index
revising the entries for diagnostic codes diagnostic code 7906 to read as follows: of Disabilities

Diagnostic
code No.

* * * * * * *

THE ENDOCRINE SYSTEM

7900 ......... Hyperthyroidism, including, but not limited to, Graves’ disease.
7901 ......... Thyroid enlargement, toxic.
7902 ......... Thyroid enlargement, nontoxic.

* * * * * * *
7906 ......... Thyroiditis.

* * * * * * *
7911 ......... Addison’s disease (adrenocortical insufficiency).
7912 ......... Polyglandular syndrome (multiple endocrine neoplasia, autoimmune polyglandular syndrome).

* * * * * * *

■ 4. Amend appendix C by: ACTION: Proposed rule. 3. Mail or deliver: Andrew Steckel
■ a. Adding entries for Graves’ disease. (Air–4), U.S. Environmental Protection
Polyglandular syndrome and SUMMARY: The Environmental Protection Agency Region IX, 75 Hawthorne Street,
Thyroiditis in alphabetical order; and Agency (EPA) is proposing to approve San Francisco, CA 94105–3901.
■ b. Revising the disability entry for revisions to the Feather River Air Instructions: All comments will be
Thyroid gland. The additions and Quality Management District included in the public docket without
revision read as follows: (FRAQMD) portion of the California change and may be made available
State Implementation Plan (SIP). online at www.regulations.gov,
Appendix C to Part 4—Alphabetical Included in this approval are the
Index of Disabilities including any personal information
following three SIP demonstrations from provided, unless the comment includes
FRAQMD: 2006 Reasonably Available Confidential Business Information (CBI)
Diagnostic Control Technology (RACT) Analysis for
code No. or other information whose disclosure is
State Implementation Plan (SIP), restricted by statute. Information that
November 2006; Reasonably Available you consider CBI or otherwise protected
* * * * * Control Technology State should be clearly identified as such and
Graves’ disease ........................ 7900 Implementation Plan Revision Negative should not be submitted through
Declaration for Control Techniques www.regulations.gov or email.
* * * * * Guidelines Issued 2006–2008, June 1,
Polyglandular syndrome ........... 7912 www.regulations.gov is an ‘‘anonymous
2009; and Reasonably Available Control access’’ system, and EPA will not know
Technology Analysis and Negative your identity or contact information
* * * * *
Declarations, July 3, 2014. The first two unless you provide it in the body of
Thyroid gland demonstrations address the 1997 8-hour your comment. If you send email
Nontoxic thyroid enlarge- National Ambient Air Quality Standards directly to EPA, your email address will
ment ............................... 7902 (NAAQS) for ozone, and the third be automatically captured and included
Toxic thyroid enlargement 7901 demonstration addresses the 2008 8- as part of the public comment. If EPA
Thyroiditis ................................. 7906 hour NAAQS for ozone. The submitted cannot read your comment due to
SIPs also contain negative declarations technical difficulties and cannot contact
* * * * * for volatile organic compound (VOC) you for clarification, EPA may not be
[FR Doc. 2015–16666 Filed 7–7–15; 8:45 am]
source categories for the years 2006, able to consider your comment.
2009 and 2014. We are proposing to Electronic files should avoid the use of
BILLING CODE 8320–01–P
approve the submitted SIP revisions special characters, any form of
under the Clean Air Act as amended in encryption, and be free of any defects or
1990 (CAA or the Act). We are also viruses.
ENVIRONMENTAL PROTECTION proposing to approve a local rule that
AGENCY Docket: Generally, documents in the
regulates gasoline dispending facilities. docket for this action are available
40 CFR Part 52 DATES: Any comments on this proposal electronically at www.regulations.gov
must arrive by August 7, 2015. and in hard copy at EPA Region IX, 75
srobinson on DSK5SPTVN1PROD with PROPOSALS

[EPA–R09–OAR–2015–0164; FRL–9927–77– ADDRESSES: Submit comments, Hawthorne Street, San Francisco,
Region 9]
identified by docket number EPA–R09– California 94105–3901. While all
Revisions to the California State OAR–2015–0164, by one of the documents in the docket are listed at
Implementation Plan, Feather River Air following methods: www.regulations.gov, some information
Quality Management District 1. Federal eRulemaking Portal: may be publicly available only at the
www.regulations.gov. Follow the on-line hard copy location (e.g., copyrighted
AGENCY: Environmental Protection instructions. material, large maps), and some may not
Agency (EPA). 2. Email: steckel.andrew@epa.gov. be publicly available in either location

VerDate Sep<11>2014 15:15 Jul 07, 2015 Jkt 235001 PO 00000 Frm 00031 Fmt 4702 Sfmt 4702 E:\FR\FM\08JYP1.SGM 08JYP1

Document Created: 2018-02-23 09:12:29
Document Modified: 2018-02-23 09:12:29

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 by VA on or before September 8, 2015.
Contact		Nick Olmos-Lau, M.D., FAAN, Medical Officer, Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, (211C) 810 Vermont Avenue NW., Washington, DC 20420, (202) 461-9700. (This is not a toll-free number.)
FR Citation		80 FR 39011
RIN Number		2900-AO44
CFR Associated		Disability Benefits; Pensions and Veterans