81 FR 53353 - Schedule for Rating Disabilities; Skin Conditions

DEPARTMENT OF VETERANS AFFAIRS

Federal Register Volume 81, Issue 156 (August 12, 2016)

Page Range		53353-53362
FR Document		2016-18695

The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule) that addresses skin conditions. 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 Skin Disorders Work Group, which is comprised of subject matter experts from both the Veterans Benefits Administration and the Veterans Health Administration, and comments from experts and the public gathered as part of a public forum. The public forum, focusing on revisions to the skin conditions section of the VASRD, was held in January 2012.

Federal Register, Volume 81 Issue 156 (Friday, August 12, 2016)

[Federal Register Volume 81, Number 156 (Friday, August 12, 2016)]
[Proposed Rules]
[Pages 53353-53362]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2016-18695]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP27

Schedule for Rating Disabilities; Skin Conditions

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 skin conditions. 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 Skin Disorders Work Group, which is
comprised of subject matter experts from both the Veterans Benefits
Administration and the Veterans Health Administration, and comments
from experts and the public gathered as part of a public forum. The
public forum, focusing on revisions to the skin conditions section of
the VASRD, was held in January 2012.

DATES: Comment Date: Comments must be received by VA on or before
October 11, 2016.
Applicability Date: The provisions of this rulemaking shall apply
to all applications for benefits that are received by VA or that are
pending before the agency of original jurisdiction on or after the
effective date of the final rule. The Secretary does not intend for the
provisions of this rulemaking to apply to claims that have been
certified for appeal to the Board of Veterans' Appeals or are pending
before the Board of Veterans' Appeals, the United States Court of
Appeals for Veterans Claims, or the United States Court of Appeals for
the Federal Circuit.

ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to Director, 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. (This is not a toll free number.) Comments should indicate
that they are submitted in response to ``RIN 2900-AP27-Schedule for
Rating Disabilities; Skin Conditions.'' 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: Gary Reynolds, M.D., Regulations 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 number.)

SUPPLEMENTARY INFORMATION: The National Defense Authorization Act For
Fiscal Year 2004, sec. 1501-07, Public Law 108-136, 117 Stat. 1392,
established the Veterans' Disability Benefits Commission (Commission).
Section 1502 of Public Law 108-136 mandated the Commission to study
ways to improve the disability compensation system for disabled
military veterans. The Commission consulted with the Institute of
Medicine (IOM) to review the medical aspects of the current disability
compensation policies for veterans. In 2007, the IOM released its
report titled, ``A 21st Century System for Evaluating Veterans for
Disability Benefits.''
The IOM Report was notable in several respects. The IOM observed,
in part, that the VASRD was inadequate at times because it contained
obsolete information and did not sufficiently integrate current and
accepted diagnostic procedures. In addition, the IOM observed that the
current body system organization of the VASRD does not reflect current
knowledge of the relationships between conditions and comorbidities.
Institute of Medicine, Committee on Medical Evaluation of Veterans for
Disability Compensation, ``A 21st Century System for Evaluating
Veterans for Disability Benefits,'' 113 (Michael McGeary et al. eds.
2007).
Following release of the IOM report, VA created a Skin Disorders
Work Group (Work Group). The goals adopted by the Work Group were to:
1) improve and update the criteria that VA uses to assign levels of
disability after service connection is granted; 2) improve the level of
fairness in adjudication of benefits related to service connected
disabilities of Veterans; and 3) invite public participation. The Work
Group was led by co-chairs from the Veterans Health Administration
(VHA) and Veterans Benefits Administration (VBA). The workgroup was
comprised of subject matter experts (SMEs) from within VA, DoD, and
medical academia. In addition, members from several Veterans Service
Organizations (VSOs) were invited to participate as representatives
from the public. The Work Group held a public forum in New York City
during January 2012, where several SMEs gave presentations focused on
their particular area(s) of expertise.
After the public forum, the Work Group met periodically to continue
the revision efforts. Participants from VBA, VHA, medical academia, and
VSO representatives continued work within their areas of expertise. The
regulation drafting phase began in September 2013, and continues
through the publication of this proposed rule. The rule VA proposes is
consistent with updating and improving criteria by using validated
severity ratings specific to the skin for each of the disability rating
levels. As discussed in more detail below, the newly adopted
classifications are derived from current medical practice.

Schedule of Ratings--Skin Conditions

General Rating Formula for Skin Disorders

Section 4.118 currently lists 30 diagnostic codes (DCs)
encompassing conditions involving injury or disease of the skin. VA
proposes to revise these codes, through addition, removal, or other
revisions, to reflect current medical science, terminology, and
functional impairment.
VA would delete the current introductory paragraph to Sec. 4.118.
VA added the current paragraph to explain the applicability of the 2008
amendments to Sec. 4.118, DCs 7800, 7801, 7802, 7804, and 7805. This
rulemaking would make further amendments and would render outdated the
current introductory paragraph. VA would add an applicability date
paragraph to the dates section to explain this rulemaking's
applicability. The existing provisions in Sec. 4.118 concerning review
of ratings and effective dates merely reflect generally applicable
principles that need not be restated in the rating schedule.
VA would add a new introductory paragraph to state that, for the
purposes of Sec. 4.118, systemic therapy is treatment that is
administered through any route (orally, injection, suppository,
intranasally) other than the skin, and topical therapy is treatment
that is administered through the skin. On March 1, 2016, the United
States Court

[[Page 53354]]

of Appeals for Veterans Claims (Veterans Court) found it
``unambiguous'' that the ``use of a topical corticosteroid is systemic
therapy within the meaning of Diagnostic Code 7806.'' Johnson v.
McDonald, 27 Vet. App. 497, 502, 504 (2016). Under this holding,
repeated localized application of topical corticosteroid could entitle
a veteran to a disability rating as high as sixty percent, even if the
affected area is very small. Johnson creates a dramatic disconnect
between the severity of the veteran's disability and the corresponding
rating. Therefore, VA is amending Sec. 4.118 to clearly provide that
VA does not intend for treatment administered through the skin (topical
therapy) to constitute systemic therapy. VA notes that it is possible
for topical treatments to have systemic effects if administered on a
large enough scale. However, in these situations, a veteran can obtain
a higher rating due to the percentage of the body affected, not the
mode of administration for his or her treatment. For example, if more
than 40 percent of a veteran's body is covered in eczema and a veteran
treats all affected areas with topical corticosteroid, the veteran will
be entitled to a 60 percent rating due to the percentage of the body
affected, not because he is taking systemic therapy.
VA proposes a General Rating Formula to evaluate several of the
skin disorders: dermatitis or eczema (DC 7806), discoid lupus
erythematosus (DC 7809), dermatophytosis (DC 7813), bullous disorders
(DC 7815), psoriasis (DC 7816), infections of the skin not listed
elsewhere (DC 7820), cutaneous manifestations of collagen-vascular
diseases not listed elsewhere (DC 7821), papulosquamous disorders not
listed elsewhere (DC 7822), and diseases of keratinization (DC 7824).
Individually, each of the above referenced conditions involves similar
superficial components of the skin. The severity of impairment for each
condition increases as more skin is involved. All of the conditions
have treatments which are applied directly to the skin, as well as
taken systemically (e.g., by mouth). There are still more similarities
with regard to which treatments are used, treatment dosages given,
treatment routes of administration, and treatment duration. As a
result, VA concluded it would be more efficient to rate under the same
formula, rather than to prescribe individual rating criteria.
Similar to how these DCs are currently evaluated, this General
Rating Formula accounts for percentages of areas affected, both of the
entire body and exposed areas, as well as the level of treatment
required. The percentage evaluations assigned under the General Rating
Formula mirror the percentage evaluations currently assigned for these
DCs. Specifically, VA proposes a 60 percent evaluation when at least
one of the following is present: More than 40 percent of the entire
body or more than 40 percent of exposed areas affected, or; Constant or
near-constant systemic therapy including, but not limited to,
corticosteroids, phototherapy, retinoids, biologics, photochemotherapy,
PUVA or other immunosuppressive drugs required per 12-month period. VA
proposes a 30 percent evaluation when at least one of the following is
present: 20 to 40 percent of the entire body or 20 to 40 percent of
exposed areas affected, or; Systemic therapy including, but not limited
to, corticosteroids, phototherapy, retinoids, biologics,
photochemotherapy, PUVA or other immunosuppressive drugs required for a
total duration of six weeks or more, but not constantly, per 12-month
period. VA proposes a 10 percent evaluation when at least one of the
following is present: At least 5 percent, but less than 20 percent of
the entire body affected, or; At least 5 percent, but less than 20
percent of exposed areas affected, or; Intermittent systemic therapy
including, but not limited to, corticosteroids, phototherapy,
retinoids, biologics, photochemotherapy, PUVA or other
immunosuppressive drugs required for a total duration of less than six
weeks per 12-month period. VA proposes a zero percent evaluation when
no more than topical therapy is required per 12-month period and at
least one of the following is present: Less than 5 percent of the
entire body affected, or; Less than 5 percent of exposed areas
affected.
Additionally, VA proposes to maintain the current rating
instruction for DCs 7806, 7809, 7813-7816, and 7820-7822 which allows
for evaluation under disfigurement of the head, face, or neck (DC 7800)
or scars (DCs 7801, 7802, 7804, or 7805), depending upon the
predominant disability, in lieu of using the General Rating Formula.
This rating instruction does not apply to current or new DC 7824, and
therefore, VA proposes to add a clarifying sentence to that effect to
this instruction.
As for the expanded list of systemic therapies identified in the
General Rating Formula, VA notes that the current VASRD lists only
``corticosteroids or other immunosuppressive drugs'' as examples of
systemic therapy. However, since the last review and update of the
schedule of disability ratings for the skin, a number of new systemic
therapies have surfaced that are used to treat the conditions covered
under the General Rating Formula. These include phototherapy,
retinoids, biologics, photochemotherapy, and PUVA (e.g., ultraviolet
therapy). See, e.g., Jennifer D. Peterson, MD, et al., ``A
Comprehensive Management Guide for Atopic Dermatitis,'' 18:6
Dermatology Nursing, 531-42 (2006); ``Psoriasis Medications,'' WebMD,
http://www.webmd.com/skin-problems-and-treatments/psoriasis/psoriasis-medications (last visited Aug. 25, 2015). To ensure consistent
evaluation of these conditions, VA proposes to add these systemic
therapies to the list of enumerated treatments.
In addition to creating the General Rating Formula and applying it
to DCs 7806, 7809, 7813, 7815, 7816, 7820, 7821, 7822, and 7824, VA
proposes to amend certain individual DCs within Sec. 4.118. The
particular changes affecting each DC immediately follow.

Diagnostic Codes 7801 and 7802

Each of these DCs pertains to types of scars which are, in part,
characterized as ``nonlinear.'' To broaden application of these DCs, VA
proposes to remove the reference to ``nonlinear'' from each DC title.
In addition, VA proposes to include a more descriptive reference to
whether the scar involves underlying soft tissue damage in place of the
current terms ``superficial'' and ``deep''--to assist rating personnel.
This latter proposed change eliminates the need for current note (1) in
each DC, as well as the last sentence in note (2) in each DC;
therefore, VA proposes removal of those items.
Currently, if a scar runs in two or more separate areas of the
body, note (2) for DCs 7801 and 7802 is intended to allow for the
assignment of a separate evaluation for each affected zone and then to
combine those evaluations under 38 CFR 4.25. See 73 FR 54708, 54709,
Sept. 23, 2008. Although VA has been applying note (2) in this way, VA
finds that the note could be written more clearly. Therefore, VA
proposes to rewrite note (2) in a clearer and more concise manner and
to add a new note (1) to be placed under both DCs 7801 and 7802 that
would define the zones of the body. Specifically, note (1) would define
the six zones of the body as each extremity, the anterior trunk, and
the posterior trunk. VA also proposes to move the statement that the
midaxillary line is what divides the anterior and posterior trunk from
note (2) to note (1).
Additionally, VA proposes to add language to note (2) to allow for
an alternative evaluation. Specifically, VA proposes to allow for a
single evaluation

[[Page 53355]]

under DCs 7801 and 7802 if adding the entire affected zones of the body
together would result in a higher evaluation. VA proposes this
additional evaluation method in order to accurately reflect the level
of disability present. In some circumstances, combining the scars from
different zones under Sec. 4.25 results in a lower compensation level
than if the total scar area was added together without regard to the
zone involved. For example, under DC 7801, if there is a single scar of
6 square inches total equally affecting both the anterior and posterior
trunk, a compensable rating would not be warranted because the area
affecting each zone would be less than 6 square inches total (e.g., 3
square inches on the anterior trunk and 3 square inches on the
posterior trunk). However, when adding these scar segments together to
consider the total square area (6 square inches), a 10 percent
evaluation would be warranted. Similarly, under DC 7802, there may be
scars in separate zones that are not each 144 square inches, but which
add up to 144 square inches total. For example, a veteran may have a
100 square inch scar on the anterior trunk and a 100 square inch scar
on the posterior trunk, which would not warrant a compensable rating
under DC 7802. However, an evaluation of 10 percent would be warranted
by adding the affected zones together for both scars, as they total to
200 square inches together.

Diagnostic Code 7803

This DC was deleted in October 2008. See 73 FR at 54710. However,
several criteria reference this code. VA proposes to delete any and all
references to DC 7803.

Diagnostic Code 7805

VA proposes to remove the reference to ``linear'' scars from DC
7805. The result of this change is that this DC applies to both linear
and non-linear scars. As discussed above, VA proposes to remove the
reference to ``nonlinear'' scars from DCs 7801 and 7802, expanding
application of these codes to linear scars. Thus, the reference to
linear scars should be removed from DC 7805 to avoid confusion by
rating personnel.

Diagnostic Codes 7809 and 7821

VA proposes to retitle both DC 7809 and DC 7821 using current
medical terminology. Current DC 7809 refers to ``Discoid lupus
erythematosus or subacute cutaneous lupus erythematosus.'' VA proposes
to remove the listed condition ``subacute cutaneous lupus
erythematosus'' from DC 7809 and add it to DC 7821. The proposed DC
7809 will read as ``Discoid lupus erythematosus. Current DC 7809 also
provides that a rating under DC 7809 should not be combined with a
rating under DC 6350. In order to maintain this provision, we would add
a note to DC 7809. The rationale for transferring subacute cutaneous
lupus erythematosus from DC 7809 to DC 7821 is that subacute cutaneous
lupus erythematosus is a distinctly different condition which is more
analogous to collagen-vascular diseases not listed elsewhere (e.g., DC
7821) than it is to discoid lupus erythematosus. See Jean L. Bolognia,
John L. Jorrizo, et al. eds., ``Dermatology,'' 618-20 (3d ed. 2012).
The proposed DC 7821 will read as ``Cutaneous manifestations of
collagen-vascular diseases not listed elsewhere (including scleroderma,
calcinosis cutis, subacute cutaneous lupus erythematosus, and
dermatomyositis).'' There is no change in the evaluation criteria; both
conditions would be rated under the General Rating Formula.

Diagnostic Code 7813

Current DC 7813 describes a number of variations of
dermatophytosis, including tinea corporis, tinea capitis, tinea pedis,
tinea barbae, tinea unguium, and tinea cruris. To update this DC title
with current medical terminology, VA proposes to add ``tinea
versicolor'' to this list as well as a parenthetical for tinea
unguium--onychomycosis as these are also common variations of
dermatophytosis seen in the veteran population. Id. at 1251-84. As
previously discussed above, VA intends to rate conditions covered by DC
7813 under the General Rating Formula, which provides for similar
evaluation criteria as are currently in effect.

Diagnostic Codes 7815 and 7816

Current medical practice indicates conditions rated under DC 7815
(bullous disorders) and DC 7816 (psoriasis) can affect additional areas
beyond the skin (bullous disorders can affect mucosa of the ocular,
oral, gastrointestinal, respiratory, and genitourinary tracts;
psoriasis can affect oral mucosa, nails and the joints). Id. at 142,
148-55, 472-73, 482, and 487-89. Therefore, in addition to rating these
conditions under the General Rating Formula, VA proposes a note for
each of these DCs. The note to DC 7815 would instruct the rater to rate
complications and residuals of mucosal involvement (ocular, oral,
gastrointestinal, respiratory, and genitourinary) separately under the
appropriate diagnostic code. The note to DC 7816 would instruct the
rater to rate complications such as psoriatic arthritis and other
clinical manifestations (oral mucosa, nails) under the appropriate
diagnostic code.

Diagnostic Code 7817

VA proposes to retitle DC 7817, currently ``Exfoliative dermatitis
(erythroderma),'' as ``Erythroderma.'' Erythroderma is the nomenclature
being used in current medical practice. Id. at 171-81. In addition, it
proposes to update the rating criteria to reflect up-to-date medical
understanding of this condition. VA would also slightly reorganize the
presentation of criteria for ease of field use. Currently, this
condition is evaluated based upon level of involvement of the skin,
presence of systemic manifestations, and the level of treatment
required. VA does not propose any changes to the level of involvement
of the skin, presence of systemic manifestations, or the level of
treatment required. However, similar to the changes proposed in the
General Rating Formula, the new rating criteria for DC 7817 would
reflect additional systemic treatments appropriate for this condition.
Currently, DC 7817 includes corticosteroids, immunosuppressive
retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB
(ultraviolet-B light) treatments, or electron beam therapy. VA proposes
to add biologics to this list as several biological therapies have been
approved for treatment of skin disorders in recent years. See M.
Viguier, et al., ``Efficacy and Safety of Biologics in Erythrodermic
Psoriasis,'' The British J. of Dermatology 167(2): 417-23 (2012). VA
proposes that inclusion of this type of systemic therapy in the rating
criteria would ensure consistent and accurate evaluations.
In addition to expanding the list of systemic therapies listed, VA
proposes to include a criterion which considers an individual's level
of response to treatment for both the 60 percent and 100 percent
evaluations. Under the new criteria, VA would provide a 100 percent
rating when the veteran is not currently undergoing treatment due to a
documented history of treatment failure with 2 or more treatment
regimens and a 60 percent rating when the veteran is not currently
undergoing treatment due to a documented history of treatment failure
with 1 treatment regimen. Historically, there have been a significant
number of veterans with this disorder who fail to respond to treatment
(frequently, the condition is related to an underlying malignancy that
is not treated successfully, hence the treatment failure).

[[Page 53356]]

To assist rating personnel in applying the new rating criteria, VA
proposes to add a note to DC 7817 which defines ``treatment failure.''
Modeled after a formula developed to study the efficacy of treatment in
erythrodermic cutaneous T-cell lymphoma, VA proposes to define
``treatment failure'' as either disease progression or less than a 25
percent reduction in the extent and severity of disease after four
weeks of prescribed therapy, as documented by medical records. See
Zackheim HS, Kashani-Sabet M, et al., ``Low-dose methotrexate to treat
erythrodermic cutaneous T-cell lymphoma: Results in twenty-nine
patients,'' J. Am. Acad. of Dermatology 34(4):626-31 (1996); see also
Bolognia, supra at 181 (erythroderma usually improves within two to six
weeks of initiation).

Diagnostic Code 7822

VA proposes to update the description in this code to reflect
current medical practice. Specifically, the condition mycosis fungoides
is added to the list of papulosquamous disorders. See Bolognia, 2019-
2027. Currently, mycosis fungoides is not listed in the rating schedule
and has caused confusion among VA rating specialists on how to account
for this condition, leaving VA rating specialists to invoke Sec. 4.20,
analogous ratings. This approach could lead to inconsistent ratings for
this condition. Therefore, adding mycosis fungoides under DC 7822 would
eliminate the need for an analogous rating and provide a consistent
basis for evaluating this condition.

Diagnostic Code 7825

Chronic urticaria, also known as chronic hives, is defined as
continuous urticaria at least twice per week off treatment for a period
of six weeks or more. See Bolognia at 295. It can be caused by a number
of mechanisms (physical stimulus, or touch; autoimmune causes;
pseudoallergenic, infection-related; vasculitis-related; and,
idiopathic, or unknown). Id. at 296. Chronic urticaria is currently
evaluated based on the frequency of ``episodes'' or ``debilitating
episodes'' and type of treatment. Regarding ``episodes'' or
``debilitating episodes,'' VA believes this term is non-specific and
not helpful to rating personnel in evaluating this condition.
Therefore, VA proposes to replace this term with ``documented
urticarial attacks.'' Furthermore, VA proposes to revise all of the
rating criteria to indicate both a minimum specified frequency of
documented urticarial attacks within a 12 month period and the type of
treatment required. VA proposes this approach to the criteria to
introduce greater objectivity within the evaluation criteria based on
current medical practice. VA acknowledges that an urticarial attack
generally results in debilitation; however, this change makes it clear
that the acute period of debilitation must be related to the service-
connected skin disease itself rather than another condition.
Regarding the current 30 percent and 60 percent criteria, VA
proposes to include examples of common ``immunosuppressive therapy,''
to include, but not limited to, cyclosporine or steroids. See Bolognia,
supra at 300-05. For clarity and consistency, VA would replace the
phrase occurring ``at least four times during the past 12-month
period'' in the 30 and 60 percent criteria with ``four or more times
per 12-month period.''
VA also proposes to add two new sets of criteria under the 10
percent evaluation; the revised criteria would allow a 10 percent
evaluation to be assigned in more circumstances based upon an
individual's level of response to treatment. A 10 percent evaluation
would be assigned if there are recurrent documented urticarial attacks
occurring one to three times during the past 12-month period and
intermittent systemic immunosuppressive therapy is required for
control. VA would also assign a 10 percent evaluation if there are
recurrent documented urticarial attacks occurring four or more times
during the past 12-month period and treatment with antihistamines or
sympathomimetics (including, but not limited to an epipen or
intramuscular epinephrine) is required or, if there are no recurrent
documented urticarial attacks, but continuous systemic
immunosuppressive therapy medication is required for control
(including, but not limited to, cyclosporine, steroids). VA also
proposes to reorganize how the various criteria are presented for ease
of field use.
VA believes that a 10 percent evaluation is appropriate in each of
these cases because the treatment measures may impose slight disability
upon the individual. For example, long term treatment with
antihistamines can result in drowsiness (even the non-sedating kinds)
and autonomic nervous system dysfunction (e.g., urinary retention). Id.
at 303. Similarly, continuous use of systemic medications may result in
disabling effects, such as drowsiness with doxepin or weight gain, and
increased risk of diabetes with long-term steroid use. See Manuchair
Ebadi, ``Desk Reference of Clinical Pharmacology,'' 101, 113, 329, and
582 (2d ed. 2008); see also ``Chronic hives (urticaria),'' Mayo Clinic
(Sept. 17, 2011), http://www.mayoclinic.org/diseases-conditions/chronic-hives/basics/treatment/con-20031634 (last visited Apr. 23,
2014).

Diagnostic Code 7826

Similar to DC 7825, VA proposes to update the criteria under
current DC 7826, ``Vasculitis, primary cutaneous.'' First, VA proposes
to replace the term ``debilitating episodes,'' which is a non-specific
term not defined in the VASRD with the term ``documented vasculitic
episodes.'' This change in terminology is more consistent with current
medical practice. Next, VA proposes to modify the criteria to specify
the minimum frequency of documented vasculitic episodes, the type of
treatment required and the effectiveness of that treatment. In turn,
increased disability would be reflected in objective terms (e.g.,
increased frequency of vasculitic episodes, more intensive treatment or
lack of treatment effectiveness). VA also proposes to reorganize how
the various criteria are presented for ease of field use. These
modifications incorporate current medical knowledge, enhance
objectivity and are easier for rating personnel to utilize.
For the 60 percent level of compensation, VA proposes to remove the
phrase ``occurring at least four times during the past 12 month
period'' and replace the term ``recurrent'' with ``persistent'' and the
term ``despite'' with the phrase ``refractory to.'' The phrase removal
and term replacements are to more clearly differentiate between the 60
percent and 30 percent compensation levels. For the 30 percent
evaluation, VA proposes to replace the phrase ``. . . at least four
times during the past 12-month period . . .'' with the phrase ``four or
more times per 12-month period'' to clearly delineate the minimal
frequency requirement and ease of field use. For the 10 percent
evaluation, VA proposes to replace the phrase ``one to three times
during the past 12-month period'' with ``one to three times per 12-
month period'' for ease of field use. Additionally for the 10 percent
evaluation, VA proposes to add that the absence of recurrent documented
vasculitic episodes but requiring continuous systemic medication for
control would also warrant compensation. This proposed revision allows
a 10 percent evaluation to be assigned in more circumstances, namely,
when the disorder is controlled through the use of systemic
medications, but there may be slight disabling effects as a result of
such medication. See Ebadi, supra; see also

[[Page 53357]]

``Vasculitis,'' Mayo Clinic (Oct. 8, 2011), http://www.mayoclinic.org/diseases-conditions/vasculitis/basics/treatment/con-20026049 (last
visited Apr. 23, 2014).

Diagnostic Code 7827

VA proposes to revise and update the criteria for DC 7827,
``Erythema multiforme; Toxic epidermal necrolysis.'' First, each
evaluation level would reference the presence of mucosal (leading to
impaired mastication, that is, chewing), palmar (leading to impaired
handgrip), or plantar involvement (leading to impaired ambulation, that
is, walking). See Bolognia, supra at 320, 322, and 326-32. The mucosal,
palmar, and/or plantar findings would be restricted to the past 12-
month period for all evaluation levels. For clarity and consistency, VA
would replace the phrase occurring ``at least four times during the
past 12-month period'' in the 30 and 60 percent criteria with ``four or
more times per 12-month period.'' For a 60 percent evaluation,
recurrent mucosal, palmar, or plantar involvement impairing
mastication, use of hands, or ambulation occurring four or more times
per 12-month period despite ongoing immunosuppresive therapy would be
required. For a 30 percent evaluation, recurrent mucosal, palmar, or
plantar involvement not impairing mastication, use of hands, or
ambulation occurring four or more times per 12-month period, and
requiring intermittent systemic therapy would be required.
A 10 percent evaluation would be assigned for the following
circumstances: (1) One to three episodes of mucosal, palmar, or plantar
involvement not impairing mastication, use of hands, or ambulation
occurring per 12-month period AND requiring intermittent systemic
therapy, or (2) without recurrent episodes, but requiring continuous
systemic medication for control. This allows a 10 percent evaluation to
be assigned in more circumstances, based upon the level of response to
treatment. Lastly, VA proposes to add a note at the end of DC 7827
defining, for the purposes of DC 7827 only, that systemic therapy may
consist of one or more of the following treatment agents:
Immunosuppressives, antihistamines, or sympathomimetics. See Ebadi,
supra; see also Victor Cohen, PharmD, et al., ``Toxic Epidermal
Necrolysis Treatment & Management,'' MEDSCAPE REFERENCE (Mar. 3, 2014),
http://emedicine.medscape.com/article/229698-treatment#a1156 (last
visited Apr. 23, 2014).

Diagnostic Code 7828

VA proposes to update DC 7828, ``Acne,'' by removing the reference
to ``superficial cysts'' in the zero percent rating criteria. This
update is proposed based upon current medical terminology as the term
``superficial cysts'' is no longer used in the medical community. See
Bolognia, supra at 547-50 and 555-58.

Diagnostic Code 7829

Current DC 7829 instructs rating personnel to evaluate chloracne
based, in part, on either the presence of deep or superficial acne. The
current evaluation criteria instructs that either a 10 or 30 percent
evaluation should be assigned depending upon whether more or less than
40 percent of the face and neck are involved; VA does not propose
changes to these criteria. However, a 10 percent evaluation is also
assigned when there is ``deep acne other than on the face and neck.''
VA proposes to clarify that a 10 percent evaluation should only be
assigned when deep acne affects non-intertriginous areas of the body
other than the face and neck or less than 40 percent of the face and
neck. Intertriginous areas of the body include the axilla of the arm,
the anogenital region, and skin folds of the breast or between digits.
Samuel T. Selden, MD, ``Intertrigo,''Medscape Reference (Mar. 27,
2012), http://emedicine.medscape.com/article/1087691-overview (last
visited Apr. 23, 2014). Deep acne affecting these areas of the body
results in greater functional impairment to the individual because
these represent more sensitive areas of the body. Therefore, VA
proposes to assign a higher 20 percent evaluation when deep acne
affects the intertriginous areas of the body.
Additionally, for reasons previously discussed in DC 7828, VA
proposes to remove the term ``superficial cysts'' from the rating
criteria under the zero percent evaluation. See Bolognia, supra at 547-
50 and 555-58.

Technical Amendments

VA also proposes several technical amendments. We 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 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 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 the 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 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.

Unfunded Mandates

The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of

[[Page 53358]]

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 numbers and titles for
the programs affected by this document are 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. Gina S.
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs,
approved this document on August 1, 2016, for publication.

List of Subjects in 38 CFR Part 4

Disability benefits, Pensions, Veterans.

Dated: August 1, 2016.
Jeffrey Martin,
Office Program Manager, Office of Regulation Policy & Management,
Office of the Secretary, Department of Veterans Affairs.

For the reasons set out in the preamble, the Department of Veterans
Affairs proposes to amend 38 CFR part 4, subpart B as follows:

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. 4.118 by:
0
a. Revising the introductory paragraph;
0
b. Revising the entries for diagnostic codes 7801, 7802, and 7805;
0
c. Adding an entry for ``General Rating Formula For The Skin For DCs
7806, 7809, 7813-7816, 7820-7822, And 7824'', to appear after the entry
for diagnostic code 7805;
0
d. Revising entries for diagnostic codes 7806, 7809, 7813, 7815, 7816,
7817, 7820, 7821, 7822, 7824, 7825, 7826, 7827, 7828, and 7829.
The revisions and additions read as follows:

Sec. 4.118 Schedule of ratings-skin.

For the purposes of this section, systemic therapy is treatment
that is administered through any route (orally, injection, suppository,
intranasally) other than the skin. For the purposes of this section,
topical therapy is treatment that is administered through the skin.

------------------------------------------------------------------------
Rating
------------------------------------------------------------------------

* * * * * * *
7801 Burn scar(s) or scar(s) due to other causes, not of
the head, face, or neck, that are associated with
underlying soft tissue damage:
Area or areas of 144 square inches (929 sq. cm.) or 40
greater...............................................
Area or areas of at least 72 square inches (465 sq. 30
cm.) but less than 144 square inches (929 sq. cm.)....
Area or areas of at least 12 square inches (77 sq. cm.) 20
but less than 72 square inches (465 sq. cm.)..........
Area or areas of at least 6 square inches (39 sq. cm.) 10
but less than 12 square inches (77 sq. cm.)...........
Note (1): For the purposes of DCs 7801 and 7802, the
six (6) zones of the body are defined as each
extremity, anterior trunk and posterior trunk. The
midaxillary line divides the anterior trunk from the
posterior trunk.......................................
Note (2): A separate evaluation may be assigned for
each affected zone of the body under this diagnostic
code if there are multiple scars, or a single scar,
affecting multiple zones of the body. Combine the
separate evaluations under Sec. 4.25. Alternatively,
if a higher evaluation would result from adding the
areas affected from multiple zones of the body, a
single evaluation may also be assigned under this
diagnostic code.......................................
7802 Burn scar(s) or scar(s) due to other causes, not of
the head, face, or neck, that are not associated with
underlying soft tissue damage:
Area or areas of 144 square inches (929 sq. cm.) or 10
greater...............................................
Note (1): For the purposes of DCs 7801 and 7802, the
six (6) zones of the body are defined as each
extremity, anterior trunk and posterior trunk. The
midaxillary line divides the anterior trunk from the
posterior trunk.......................................
Note (2): A separate evaluation may be assigned for
each affected zone of the body under this diagnostic
code if there are multiple scars, or a single scar,
affecting multiple zones of the body. Combine the
separate evaluations under Sec. 4.25. Alternatively,
if a higher evaluation would result from adding the
areas affected from multiple zones of the body, a
single evaluation may also be assigned under this
diagnostic code.......................................

* * * * * * *
7805 Scars, other; and other effects of scars evaluated
under diagnostic codes 7800, 7801, 7802, and 7804:
Evaluate any disabling effect(s) not considered in a
rating provided under diagnostic codes 7800-04 under
an appropriate diagnostic code........................
General Rating Formula For The Skin For DCs 7806, 7809,
7813-7816, 7820-7822, And 7824:
At least one of the following
More than 40 percent of the entire body or more 60
than 40 percent of exposed areas affected, or;....
Constant or near-constant systemic therapy
including, but not limited to, corticosteroids,
phototherapy, retinoids, biologics,
photochemotherapy, PUVA or other immunosuppressive
drugs required per 12-month period................
At least one of the following.......................... 30
20 to 40 percent of the entire body or 20 to 40
percent of exposed areas affected, or;

[[Page 53359]]

Systemic therapy including, but not limited to,
corticosteroids, phototherapy, retinoids,
biologics, photochemotherapy, PUVA or other
immunosuppressive drugs required for a total
duration of six weeks or more, but not constantly,
per 12-month period...............................
At least one of the following.......................... 10
At least 5 percent, but less than 20 percent of the
entire body affected, or;
At least 5 percent, but less than 20 percent of
exposed areas affected, or;
Intermittent systemic therapy including, but not
limited to, corticosteroids, phototherapy,
retinoids, biologics, photochemotherapy, PUVA or
other immunosuppressive drugs required for a total
duration of less than six weeks per 12-month
period............................................
No more than topical therapy required per 12-month 0
period and at least one of the following..............
Less than 5 percent of the entire body affected,
or;
Less than 5 percent of exposed areas affected......
Or rate as disfigurement of the head, face or neck (DC
7800) or scars (DCs 7801, 7802, 7804, or 7805),
depending upon the predominant disability. This rating
instruction does not apply to DC 7824.................
7806 Dermatitis or eczema.
Evaluate under the General Rating Formula for the Skin.

* * * * * * *
7809 Discoid lupus erythematosus.
Evaluate under the General Rating Formula for the Skin.
Note: Do not combine with ratings under DC 6350........

* * * * * * *
7813 Dermatophytosis (ringworm: of body, tinea corporis; of
head, tinea capitis; of feet, tinea pedis; of beard area,
tinea barbae; of nails, tinea unguium (onychomycosis); of
inguinal area (jock itch), tinea cruris; tinea versicolor)
Evaluate under the General Rating Formula for the Skin.
7815 Bullous disorders (including pemphigus vulgaris,
pemphigus foliaceous, bullous pemphigoid, dermatitis
herpetiformis, epidermolysis bullosa acquisita, benign
chronic familial pemphigus (Hailey-Hailey), and porphyria
cutanea tarda)............................................
Evaluate under the General Rating Formula for the Skin.
Note: Rate complications and residuals of mucosal
involvement (ocular, oral, gastrointestinal,
respiratory, and genitourinary) separately under the
appropriate diagnostic code...........................
7816 Psoriasis.............................................
Evaluate under the General Rating Formula for the Skin.
Note: Rate complications such as psoriatic arthritis
and other clinical manifestations (oral mucosa, nails)
under the appropriate diagnostic code.................
7817 Erythroderma:
Generalized involvement of the skin with systemic
manifestations (such as fever, weight loss, and
hypoproteinemia) AND one of the following:
Constant or near-constant systemic therapy such as
therapeutic doses of corticosteroids,
immunosuppressive retinoids, PUVA (psoralen with
long-wave ultraviolet-A light); UVB (ultraviolet-B
light) treatments, biologics, or electron beam
therapy required per 12-month period, or
No current treatment due to a documented history of 100
treatment failure with 2 or more treatment
regimens..........................................
Generalized involvement of the skin without systemic
manifestations and one of the following:..............
Constant or near-constant systemic therapy such as
therapeutic doses of corticosteroids,
immunosuppressive retinoids, PUVA (psoralen with
long-wave ultraviolet-A light); UVB (ultraviolet-B
light) treatments, biologics, or electron beam
therapy required per 12-month period, or
No current treatment due to a documented history of 60
treatment failure with 1 treatment regimen........
Any extent of involvement of the skin, and any of the 30
following therapies required for a total duration of
six weeks or more, but not constantly, per 12-month
period: Systemic therapy such as therapeutic doses of
corticosteroids, immunosuppressive retinoids, PUVA
(psoralen with long-wave ultraviolet-A light) or UVB
(ultraviolet-B light) treatments, biologics, or
electron beam therapy.................................
Any extent of involvement of the skin, and any of the 10
following therapies required for a total duration of
less than six weeks per 12-month period: Systemic
therapy such as therapeutic doses of corticosteroids,
immunosuppressive retinoids, PUVA (psoralen with long-
wave ultraviolet-A light) or UVB (ultraviolet-B light)
treatments, biologics, or electron beam therapy.......
Any extent of involvement of the skin, and; no more 0
than topical therapy required per 12-month period.....
Note: Treatment failure is defined as either disease
progression, or less than a 25 percent reduction in
the extent and severity of disease after four weeks of
prescribed therapy, as documented by medical records..

* * * * * * *
7820 Infections of the skin not listed elsewhere (including
bacterial, fungal, viral, treponemal and parasitic
diseases).
Evaluate under the General Rating Formula for the Skin.
7821 Cutaneous manifestations of collagen-vascular diseases
not listed elsewhere (including scleroderma, calcinosis
cutis, subacute cutaneous lupus erythematosus, and
dermatomyositis)..........................................
Evaluate under the General Rating Formula for the Skin.
7822 Papulosquamous disorders not listed elsewhere
(including lichen planus, large or small plaque
parapsoriasis, pityriasis lichenoides et varioliformis
acuta (PLEVA), lymphomatoid papulosus, mycosis fungoides,
and pityriasis rubra pilaris (PRP)).......................
Evaluate under the General Rating Formula for the Skin.

* * * * * * *
7824 Diseases of keratinization (including icthyoses,
Darier's disease, and palmoplantar keratoderma).
Evaluate under the General Rating Formula for the Skin.
7825 Urticaria:
Recurrent documented urticarial attacks occurring four 60
or more times per 12-month period despite continuous
immunosuppressive therapy (including, but not limited
to, cyclosporine and steroids)........................

[[Page 53360]]

Recurrent documented urticarial attacks occurring four 30
or more times per 12-month period and requiring
intermittent systemic immunosuppressive therapy
(including, but not limited to, cyclosporine and
steroids) for control.................................
At least one of the following.......................... 10
Recurrent documented urticarial attacks occurring
one to three times per 12-month period, and
requiring intermittent systemic immunosuppressive
therapy for control, or
Recurrent documented urticarial attacks occurring
four or more times per 12-month period, and
requiring treatment with antihistamines or
sympathomimetics (including, but not limited to an
epipen or intramuscular epinephrine), or
Without recurrent documented urticarial attacks,
but requiring continuous systemic
immunosuppressive therapy medication (including,
but not limited to, cyclosporine and steroids) for
control...........................................
7826 Vasculitis, primary cutaneous:
Persistent documented vasculitis episodes refractory to 60
continuous immunosuppressive therapy..................
All of the following................................... 30
Recurrent documented vasculitic episodes occurring
four or more times per 12-month period, and
Requiring intermittent systemic immunosuppressive
therapy for control...............................
At least one of the following.......................... 10
Recurrent documented vasculitic episodes occurring
one to three times per 12-month period, and
requiring intermittent systemic immunosuppressive
therapy for control, or
Without recurrent documented vasculitic episodes
but requiring continuous systemic medication for
control...........................................
Or rate as disfigurement of the head, face, or neck
(DC 7800) or scars (DC's 7801, 7802, 7804, or
7805), depending upon the predominant disability..
7827 Erythema multiforme; Toxic epidermal necrolysis:
Recurrent mucosal, palmar, or plantar involvement 60
impairing mastication, use of hands, or ambulation
occurring four or more times per 12-month period
despite ongoing immunosuppresive therapy..............
All of the following................................... 30
Recurrent mucosal, palmar, or plantar involvement
not impairing mastication, use of hands, or
ambulation occurring four or more times per 12-
month period, and
Requiring intermittent systemic therapy............
At least one of the following.......................... 10
One to three episodes of mucosal, palmar, or
plantar involvement not impairing mastication, use
of hands, or ambulation occurring per 12-month
period AND requiring intermittent systemic
therapy, or
Without recurrent episodes, but requiring
continuous systemic medication for control........
Or rate as disfigurement of the head, face, or neck (DC
7800) or scars (DC's 7801, 7802, 7804, or 7805),
depending upon the predominant disability.............
Note: For the purposes of this DC only, systemic
therapy may consist of one or more of the following
treatment agents: Immunosuppressives, antihistamines,
or sympathomimetics...................................
7828 Acne:
Deep acne (deep inflamed nodules and pus-filled cysts) 30
affecting 40 percent or more of the face and neck.....
Deep acne (deep inflamed nodules and pus-filled cysts) 10
affecting less than 40 percent of the face and neck,
or; deep acne other than on the face and neck.........
Superficial acne (comedones, papules, pustules) of any 0
extent................................................
Or rate as disfigurement of the head, face, or neck (DC
7800) or scars (DC's 7801, 7802, 7804, or 7805),
depending upon the predominant disability.............
7829 Chloracne:
Deep acne (deep inflamed nodules and pus-filled cysts) 30
affecting 40 percent or more of the face and neck.....
Deep acne (deep inflamed nodules and pus-filled cysts) 20
affecting the intertriginous areas (the axilla of the
arm, the anogenital region, skin folds of the breasts
or between digits)....................................
Deep acne (deep inflamed nodules and pus-filled cysts) 10
affecting less than 40 percent of the face and neck;
or, deep acne affecting non-intertriginous areas of
the body (other than the face and neck)...............
Superficial acne (comedones, papules, pustules) of any 0
extent................................................
Or rate as disfigurement of the head, face, or neck (DC
7800) or scars (DC's 7801, 7802, 7804, or 7805),
depending upon the predominant disability.............

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

(Authority: 38 U.S.C. 1155)

0
3. Amend appendix A to part 4, under the entry Sec. 4.118, by:
0
a. Revising the entries for diagnostic codes 7801, 7802, 7805, 7806,
7809, 7813, 7815, 7816, and 7817;
0
b. Removing the entry for 7820-7833;
0
c. Adding entries for diagnostic codes 7820, 7821, 7822, 7823, 7824,
7825, 7826, 7827, 7828, 7829, 7830, 7831, 7832, and 7833.
The revisions and additions read as follows:

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

* * * * * * *
4.118
7801 Criterion July 6, 1950;
criterion August 30, 2002;
criterion October 23,
2008; title, note 1, note
2 [effective date of final
rule].

[[Page 53361]]

7802 Criterion September 22,
1978; criterion August 30,
2002; criterion October
23, 2008; title, note 1,
note 2 [effective date of
final rule].

* * * * * * *
7805 Criterion October 23, 2008;
title [effective date of
final rule].
General Rating Formula for
DCs 7806, 7809, 7813--
7816, 7820--7822, and 7824
added [effective date of
final rule].
7806 Criterion September 9,
1975; evaluation August
30, 2002; criterion
[effective date of final
rule].

* * * * * * *
7809 Criterion August 30, 2002;
title, criterion
[effective date of final
rule].

* * * * * * *
7813 Criterion August 30, 2002;
title, criterion
[effective date of final
rule].

* * * * * * *
7815 Evaluation August 30, 2002;
criterion, note [effective
date of final rule].
7816 Evaluation August 30, 2002;
criterion, note [effective
date of final rule].
7817 Evaluation August 30, 2002;
title, criterion, note
[effective date of final
rule].

* * * * * * *
7820 Added August 30, 2002;
criterion [effective date
of final rule].
7821 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7822 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7823 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7824 Added August 30, 2002;
criterion [effective date
of final rule].
7825 Added August 30, 2002;
criterion [effective date
of final rule].
7826 Added August 30, 2002;
criterion [effective date
of final rule].
7827 Added August 30, 2002;
criterion [effective date
of final rule].
7828 Added August 30, 2002;
criterion [effective date
of final rule].
7829 Added August 30, 2002;
criterion [effective date
of final rule].
7830 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7831 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7832 Added August 30, 2002;
title, criterion
[effective date of final
rule].
7833 Added August 30, 2002;
title, criterion
[effective date of final
rule].

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

0
4. Amend appendix B to part 4, under the center heading The Skin,, by
revising the entries for diagnostic codes 7801, 7802, 7805, 7809, 7813,
7817, 7821, and 7822 to read as follows:

Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic Code No.
------------------------------------------------------------------------

* * * * * * *
------------------------------------------------------------------------
THE SKIN
------------------------------------------------------------------------

* * * * * * *
7801.......................... Burn scar(s) or scar(s) due to other
causes, not of the head, face, or neck
that are associated with underlying
soft tissue damage.
7802.......................... Burn scar(s) or scar(s) due to other
causes, not of the head, face, or neck
that are not associated with underlying
soft tissue damage.

* * * * * * *
7805.......................... Scars, other; and other effects of scars
evaluated under diagnostic codes 7800,
7801, 7802, and 7804.

* * * * * * *
7809.......................... Discoid lupus erythematosus.

* * * * * * *
7813.......................... Dermatophytosis.

[[Page 53362]]

* * * * * * *
7817.......................... Erythroderma.

* * * * * * *
7821.......................... Cutaneous manifestations of collagen-
vascular diseases not listed elsewhere
(including scleroderma, calcinosis
cutis, subacute cutaneous lupus
erythematosus, and dermatomyositis).
7822.......................... Papulosquamous disorders not listed
elsewhere.

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

0
5. Amend appendix C to part 4 by:
0
a. Removing the entry ``Cutaneous manifestations of collagen-vascular
diseases'' and add in its place an entry for ``Cutaneous manifestations
of collagen-vascular diseases not listed elsewhere (including
scleroderma, calcinosis cutis, subacute cutaneous lupus erythematosus,
and dermatomyositis)'';
0
b. Adding in alphabetical order entries for ``Discoid lupus
erythematosus'', and ``Erythroderma''; and
0
c. Revising the entries under ``Scars.''
The additions and revisions read as follows:

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

* * * * * * *
Cutaneous manifestations of collagen-vascular diseases 7821
not listed elsewhere (including scleroderma, calcinosis
cutis, subacute cutaneous lupus erythematosus, and
dermatomyositis).......................................

* * * * * * *
Discoid lupus erythematosus............................. 7809

* * * * * * *
Erythroderma............................................ 7817

* * * * * * *
Scars:
Burn scar(s) of the head, face, or neck; scar(s) of 7800
the head, face, or neck due to other causes; or
other disfigurement of the head, face, or neck.....
Burn scar(s) or scar(s) due to other causes, not of 7801
the head, face, or neck that are associated with
underlying soft tissue damage......................
Burn scar(s) or scar(s) due to other causes, not of 7802
the head, face, or neck that are not associated
with underlying soft tissue damage.................
Retina.............................................. 6011
Scars, other; and other effects of scars evaluated 7805
under diagnostic codes 7800, 7801, 7802, and 7804..
Unstable or painful................................. 7804

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

[FR Doc. 2016-18695 Filed 8-11-16; 8:45 am]
BILLING CODE 8320-01-P

$Federal Register / Vol. 81, No. 156 / Friday, August 12, 2016 / Proposed Rules 53361 APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946—Continued Diagnostic Section Code No. 7802 Criterion September 22, 1978; criterion August 30, 2002; criterion October 23, 2008; title, note 1, note 2 [effective date of final rule]. * * * * * * * 7805 Criterion October 23, 2008; title [effective date of final rule]. General Rating Formula for DCs 7806, 7809, 7813—7816, 7820—7822, and 7824 added [effective date of final rule]. 7806 Criterion September 9, 1975; evaluation August 30, 2002; criterion [effective date of final rule]. * * * * * * * 7809 Criterion August 30, 2002; title, criterion [effective date of final rule]. * * * * * * * 7813 Criterion August 30, 2002; title, criterion [effective date of final rule]. * * * * * * * 7815 Evaluation August 30, 2002; criterion, note [effective date of final rule]. 7816 Evaluation August 30, 2002; criterion, note [effective date of final rule]. 7817 Evaluation August 30, 2002; title, criterion, note [effective date of final rule]. * * * * * * * 7820 Added August 30, 2002; criterion [effective date of final rule]. 7821 Added August 30, 2002; title, criterion [effective date of final rule]. 7822 Added August 30, 2002; title, criterion [effective date of final rule]. 7823 Added August 30, 2002; title, criterion [effective date of final rule]. 7824 Added August 30, 2002; criterion [effective date of final rule]. 7825 Added August 30, 2002; criterion [effective date of final rule]. 7826 Added August 30, 2002; criterion [effective date of final rule]. 7827 Added August 30, 2002; criterion [effective date of final rule]. 7828 Added August 30, 2002; criterion [effective date of final rule]. 7829 Added August 30, 2002; criterion [effective date of final rule]. 7830 Added August 30, 2002; title, criterion [effective date of final rule]. 7831 Added August 30, 2002; title, criterion [effective date of final rule]. 7832 Added August 30, 2002; title, criterion [effective date of final rule]. 7833 Added August 30, 2002; title, criterion [effective date of final rule]. * * * * * * * ■ 4. Amend appendix B to part 4, under 7801, 7802, 7805, 7809, 7813, 7817, the center heading The Skin,, by 7821, and 7822 to read as follows: revising the entries for diagnostic codes APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES Diagnostic Code No. * * * * * * * THE SKIN * * * * * * * 7801 ................. Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are associated with underlying soft tissue damage. 7802 ................. Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are not associated with underlying soft tissue damage. * * * * * * * ehiers on DSK5VPTVN1PROD with PROPOSALS 7805 ................. Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804. * * * * * * * 7809 ................. Discoid lupus erythematosus. * * * * * * * 7813 ................. Dermatophytosis. VerDate Sep<11>2014 14:23 Aug 11, 2016 Jkt 238001 PO 00000 Frm 00028 Fmt 4702 Sfmt 4702 E:\FR\FM\12AUP1.SGM 12AUP1$

53362 Federal Register / Vol. 81, No. 156 / Friday, August 12, 2016 / Proposed Rules

APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES—Continued
Diagnostic
Code No.

* * * * * * *
7817 ................. Erythroderma.

* * * * * * *
7821 ................. Cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis,
subacute cutaneous lupus erythematosus, and dermatomyositis).
7822 ................. Papulosquamous disorders not listed elsewhere.

* * * * * * *

■ 5. Amend appendix C to part 4 by: elsewhere (including scleroderma, erythematosus’’, and ‘‘Erythroderma’’;
■ a. Removing the entry ‘‘Cutaneous calcinosis cutis, subacute cutaneous and
manifestations of collagen-vascular lupus erythematosus, and ■ c. Revising the entries under ‘‘Scars.’’
diseases’’ and add in its place an entry dermatomyositis)’’;
for ‘‘Cutaneous manifestations of ■ b. Adding in alphabetical order The additions and revisions read as
collagen-vascular diseases not listed entries for ‘‘Discoid lupus follows:

APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES
Diagnostic
Code No.

* * * * * * *
Cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis, subacute
cutaneous lupus erythematosus, and dermatomyositis) ................................................................................................................. 7821

* * * * * * *
Discoid lupus erythematosus ............................................................................................................................................................... 7809

* * * * * * *
Erythroderma ....................................................................................................................................................................................... 7817

* * * * * * *
Scars:
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 ............................................................................................................................................................. 7800
Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are associated with underlying soft tissue
damage ..................................................................................................................................................................................... 7801
Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are not associated with underlying soft tis-
sue damage .............................................................................................................................................................................. 7802
Retina ........................................................................................................................................................................................... 6011
Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804 ................................. 7805
Unstable or painful ....................................................................................................................................................................... 7804

* * * * * * *

[FR Doc. 2016–18695 Filed 8–11–16; 8:45 am] ACTION: Proposed rule. non-substantive edits for clarity, such as
BILLING CODE 8320–01–P standardizing the citation format.
SUMMARY: The Environmental Protection DATES: Comments must be received on
Agency (EPA) proposes to approve State or before September 12, 2016.
ENVIRONMENTAL PROTECTION Implementation Plan revisions
AGENCY submitted by the Washington State ADDRESSES: Submit your comments,
Department of Ecology (Ecology) on July identified by Docket ID No. EPA–R10–
40 CFR Part 52 11, 2016. The revisions update the OAR–2016–0394 at http://
incorporation by reference of Federal www.regulations.gov. Follow the online
[EPA–R10–OAR–2016–0394, FRL–9950–55– instructions for submitting comments.
Region 10] provisions cited in Ecology’s general air
Once submitted, comments cannot be
ehiers on DSK5VPTVN1PROD with PROPOSALS

quality regulations. The revisions also
Approval and Promulgation of edited or removed from Regulations.gov.
reflect changes to the primary and
Implementation Plans; Washington: The EPA may publish any comment
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Updates to Incorporation by Reference received to its public docket. Do not
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and Miscellaneous Revisions submit electronically any information
promulgated since Ecology’s last you consider to be Confidential
AGENCY: Environmental Protection update. Ecology also made minor Business Information (CBI) or other
Agency (EPA). corrections to typographical errors and information whose disclosure is

VerDate Sep<11>2014 14:23 Aug 11, 2016 Jkt 238001 PO 00000 Frm 00029 Fmt 4702 Sfmt 4702 E:\FR\FM\12AUP1.SGM 12AUP1

Document Created: 2018-02-09 11:32:55
Document Modified: 2018-02-09 11:32:55

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		Comment Date: Comments must be received by VA on or before October 11, 2016.
Contact		Gary Reynolds, M.D., Regulations 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 number.)
FR Citation		81 FR 53353
RIN Number		2900-AP27
CFR Associated		Disability Benefits; Pensions and Veterans