Schedule for Rating Disabilities: Neurological Conditions and Convulsive Disorders

DEPARTMENT OF VETERANS AFFAIRS <CFR>38 CFR Parts 3 and 4</CFR> <RIN>RIN 2900-AQ73</RIN> <SUBJECT>Schedule for Rating Disabilities: Neurological Conditions and Convulsive Disorders</SUBJECT> <HD SOURCE="HED">AGENCY:</HD> Department of Veterans Affairs. <HD SOURCE="HED">ACTION:</HD> Proposed rule. <SUM> <HD SOURCE="HED">SUMMARY:</HD> The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule) that addresses neurological conditions and convulsive disorders. The purpose of these changes is to incorporate medical advancements that have occurred since the last revision, update current medical terminology, and provide clear evaluation criteria. The proposed rule reflects advances in medical knowledge and recommendations contained in the report from the Institute of Medicine, part of the National Academy of Sciences, titled “A 21st Century System for Evaluating Veterans for Disability Benefits,” National Academies Press, 2007. </SUM> <EFFDATE> <HD SOURCE="HED">DATES:</HD> Comments must be received on or before January 13, 2025. </EFFDATE> <HD SOURCE="HED">ADDRESSES:</HD> Comments must be submitted through <E T="03">www.regulations.gov</E> . Except as provided below, comments received before the close of the comment period will be available at <E T="03">www.regulations.gov</E> for public viewing, inspection, or copying, including any personally identifiable or confidential business information that is included in a comment. We post the comments received before the close of the comment period on <E T="03">www.regulations.gov</E> as soon as possible after they have been received. VA will not post on <E T="03">Regulations.gov</E> public comments that make threats to individuals or institutions or suggest that the commenter will take actions to harm an individual. VA encourages individuals not to submit duplicative comments; however, we will post comments from multiple unique commenters even if the content is identical or nearly identical to other comments. Any public comment received after the comment period's closing date is considered late and will not be considered in the final rulemaking. In accordance with the Providing Accountability Through Transparency Act of 2023, a plain language summary (not more than 100 words in length) of this proposed rule is available at <E T="03">www.regulations.gov</E> , under RIN 2900-AQ73. <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Gary Reynolds, M.D., Medical Officer, Part 4 VASRD Staff (218), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, <E T="03">218VASRDPMO.VBACO@va.gov</E> , (202) 461-9700. (This is not a toll-free telephone number.) </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> VA has periodically revised portions of the Schedule for Rating Disabilities, to include the Neurological Conditions and Convulsive Disorders (herein referred to as the Neurological body system), since it was created in 1919. Important advances in the neurological sciences—particularly in the areas related to biochemistry, genetics, physiopathology, as well as electrodiagnosis and imaging of the nervous system—have produced drastic changes in the understanding of neurological diseases since the second half of the 20th century. The extent and repercussion of these advances triggered profound changes in approaches to diagnosis, classification of disease, and care of patients with neurological illnesses. As part of VA's ongoing revision of the VA Schedule for Rating Disabilities (VASRD or rating schedule), VA proposes changes to 38 Code of Federal Regulations (38 CFR) §§ 4.120 and 4.123-4.124a, which pertain to the neurological conditions and convulsive disorders. The proposed changes will: (1) update the medical terminology of certain neurological conditions and convulsive disorders; (2) add medical conditions frequently encountered but not currently found in the rating schedule; (3) refine evaluation criteria based on medical advances that have occurred since the last revision and current understanding of functional changes associated with or resulting from disease or injury (pathophysiology), and; (4) remove or modify certain diagnostic codes (DC) that are outdated or obsolete. <HD SOURCE="HD1">I. Retitle and Revise §§ 4.120 Evaluations by Comparison, 4.123 Neuritis, Cranial or Peripheral, and 4.124 Neuralgia, Cranial or Peripheral</HD> VA proposes to retitle and revise § 4.120, <E T="03">Evaluations by comparison,</E> because the approach to evaluating neurologic conditions has evolved over the time since this section was included in the 1945 rating schedule. See 29 FR 6718, 6749-6750 (May 22, 1964). As medical understanding has increased, the additional knowledge permits VA to develop evaluation criteria within the individual diagnostic codes that more accurately consider motor, sensory, and mental impairment. The instructions contained in the last sentence of § 4.120, which apply to peripheral nerves, will be updated to better align with modern medical knowledge and relocated to the revised § 4.123, titled “Cranial and peripheral nerve impairment,” paragraph (a)(1). VA proposes to relocate instructions relating to organic diseases of the central nervous system to § 4.120. See section II B. Orgranic diseases of the central nervous system below for additional detail. VA also proposes to retitle and revise §§ 4.123 <E T="03">Neuritis, cranial or peripheral</E> and 4.124 <E T="03">Neuralgia, cranial or peripheral.</E> These sections provide information regarding symptoms and evaluations associated with neuritis and neuralgia. Neuritis and neuralgia are used to describe symptoms associated with motor and sensory neuropathy involving cranial and peripheral nerves. However, VA proposes their removal in favor of more objective criteria to assess disability in the cranial and peripheral nerves. In the 1940s, the term neuritis was advanced by Dr. S.A. Kinnier Wilson as an all-encompassing term for most peripheral nerve conditions. Dr. S.A. Kinnier Wilson, “Neurology,” 279 (Ninian Bruce ed., 1970). As the field of peripheral neuropathology evolved, it became apparent that use of the term neuritis was obsolete and should be replaced by neuropathy, the preferred term for peripheral nerve diseases. While neuritis is sometimes used as a synonym for neuropathy, this use is erroneous and should only be used for certain specified inflammatory diseases. Drs. A.K. Asbury & Peter Johnson, “Neurology,” 258 (James Bennington ed., 1978). While the term neuragia is still used today, for compensation purposes, VA evaluates nerves affected by neuralgia by the sensory impairment caused by neuralgia, not the diagnosis itself. To that end, and as discussed in more detail below, VA proposes to remove neuritis as a separate ratable condition for both cranial nerves (DC series 8300) and peripheral nerves (DC series 8600) and neuralgia as a separate ratable condition for both cranial nerves (DC series 8400) and peripheral nerves (DC series 8700). VA will address evaluations for motor neuropathy and sensory neuropathy in revised § 4.123, as discussed below. The underlying purpose behind the § 4.123 revision is to provide a central location for instructions specific to cranial and peripheral nerve conditions. This revision will promote rating quality and consistency. First, VA proposes to retitle the section as “Cranial and peripheral nerve impairment.” Next, VA proposes informational language explaining, generally, how disabilities from cranial and peripheral nerve impairment are evaluated. After that, VA proposes to describe how disability from motor neuropathy (complete and incomplete paralysis) will be evaluated. Finally, VA proposes to describe how disability from sensory neuropathy will be evaluated. Concerning the general instructions described in the revised § 4.123, VA proposes to relocate to this section several instructions that are currently located in multiple areas. The current VASRD contains an instruction directly above diagnostic code 8205; this instruction explains that disability from lesions of peripheral portions of first, second, third, fourth, sixth, and eighth nerves are rated under the Organs of Special Sense. Additionally, it explains that the ratings for the cranial nerves are for unilateral involvement; when bilateral, combine but without the bilateral factor. VA proposes to revise these two sentences, add an additional sentence, and include them in § 4.123. Specifically, proposed § 4.123(a)(3) explains that a cranial nerve will be evaluated strictly as a cranial nerve, regardless of any portions which lie outside the cranium (skull). This is consistent with current medical practice which considers cranial nerves outside of the cranium as separate and distinct from other peripheral nerves. Proposed § 4.123(a)(3) further explains that the evaluations in the rating schedule for the cranial nerves are for unilateral involvement; when bilateral involvement occurs, evaluate separately, then combine under § 4.25 without using the bilateral factor. While all cranial nerves begin inside the cranium, most exit the cranium to insert at various destinations, where they function in a manner similar to peripheral nerves. Nevertheless, VA proposes to evaluate the entire nerve, uniformly, as a cranial nerve. Proposed § 4.123(a)(2) explains that disability from impairments of the first, second, third, fourth, sixth, and eighth cranial nerves will be rated under the Organs of Special Sense. Additionally, the current VASRD contains an instruction directly above diagnostic code 8510; this instruction states, in part, that ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with applic ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 155k characters. Full document text is stored and available for version comparison. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━