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for emergencies. The Coast Guard will disorders of the breast. VA provided a continue to be rated under diagnostic also inform the users of the waterways 60-day public comment period and code 7615. Therefore, VA makes no through our Local and Broadcast interested persons were invited to changes based on this comment. Notices to Mariners of the change in submit written comments on or before One commenter wanted to include operating schedule for the bridge so April 28, 2015. VA received 13 premature hysterectomy secondary to vessel operators may arrange their comments. menorrhagia as an additional transits to minimize any impact caused Several commenters expressed their gynecological disability in the rating by the temporary deviation. support for the proposed rule and schedule. VA evaluates service- In accordance with 33 CFR 117.35(e), thanked VA for promoting gender connected hysterectomy under the drawbridge must return to its regular equality in the rating schedule. diagnostic codes 7617 and 7618. The operating schedule immediately at the One commenter demanded cause of the hysterectomy may be a end of the effective period of this compensation for his multiple factor in determining service temporary deviation. This deviation debilitating health issues, which he connection, but is not important in from the operating regulations is attributed to exposure to toxic evaluating the condition. Therefore, VA authorized under 33 CFR 117.35. substances at Fort McClellan. He also makes no changes based on this urged VA to pass the Fort McClellan comment. Dated: April 2, 2018. Health Registry Act, H.R. 411, 113th One commenter suggested adding a Christopher J. Bisignano, Cong. (2013). Several commenters stated new diagnostic code or adjusting an Supervisory Bridge Management Specialist, their belief that their multiple medical existing code for due to the First Coast Guard District. conditions are due to exposure to toxic loss or loss of use of other organs [FR Doc. 2018–07215 Filed 4–6–18; 8:45 am] substances at Fort McClellan and asked besides the and ovaries, BILLING CODE 9110–04–P to be considered for service connection. specifically fallopian tubes. The Another commenter provided commenter asserted that, with respect to information about his medical the uterus and ovaries, the minimum DEPARTMENT OF VETERANS conditions, which he stated he rating for a condition that causes AFFAIRS developed after his reservist’s training at infertility is 20 percent and that this Fort McClellan that involved chemical rating does not take into account 38 CFR Part 4 agent training. These comments focus symptoms, only whether the organs are on issues of service connection, rather able to function reproductively. RIN 2900–AP13 than the appropriate rating for already Therefore, the commenter asserts that Schedule for Rating Disabilities; service-connected disabilities, and any damage to any part of the female Gynecological Conditions and individual claims for VA benefits, reproductive system that causes Disorders of the Breast which are beyond the scope of this infertility should result in at least a 20 rulemaking. Regarding the commenter’s percent evaluation. AGENCY: Department of Veterans Affairs. request that VA ‘‘pass’’ the Fort While tubal damage may be ACTION: Final rule. McClellan Health Registry Act, VA associated with infertility, infertility is notes that this act is a Congressional act not in itself a disability for VA rating SUMMARY: This document amends the and not before VA. This comment is purposes. It does not result in the loss Department of Veterans Affairs (VA) also beyond the scope of this of average earning capacity. See 38 CFR Schedule for Rating Disabilities rulemaking. Therefore, VA makes no 4.1 (stating that the purpose of the rating (VASRD) by revising the portion of the changes to the proposed rule based on schedule is to represent the average rating schedule that addresses these comments. impairment in earning capacity gynecological conditions and disorders One commenter had a question about resulting from diseases and injuries in of the breast. The effect of this action is the proposed note to diagnostic code civil occupations). Diagnostic code to ensure that this portion of the rating 7615 ‘‘Ovary, disease, injury, or 7614, , disease, injury, or schedule uses current medical adhesions of’’ asking if the note would adhesions of, provides disability ratings terminology and to provide detailed and create a narrow category for disability for functional impairment due to updated criteria for evaluation of evaluation by identifying symptoms associated with fallopian gynecological conditions and disorders and secondary . The tube damage. If loss or loss of use of a of the breast. commenter’s concern is not entirely creative organ due to service-connected DATES: Effective Date: This rule is clear. To the extent the commenter is fallopian tube damage is present, VA effective on May 13, 2018. asking whether VA considers will consider special monthly dysmenorrhea and secondary compensation under the provisions of FOR FURTHER INFORMATION CONTACT: amenorrhea disabilities for rating 38 CFR 3.350(a). VA makes no changes Ioulia Vvedenskaya, M.D., M.B.A., purposes, the note to diagnostic code based on this comment. Medical Officer, Part 4 VASRD 7615 provides that dysmenorrhea and The same commenter proposes to add Regulations Staff (211C), Compensation secondary amenorrhea shall be rated the diagnosis of repeated miscarriages to Service, Veterans Benefits under that diagnostic code. To the the list of presumptive conditions for Administration, Department of Veterans extent the commenter is asking whether female veterans who have been exposed Affairs, 810 Vermont Avenue NW, identification of dysmenorrhea and to radiation, herbicides, or other Washington, DC 20420, (202) 461–9700. secondary amenorrhea in the note limits environmental factors that could (This is not a toll-free telephone the application of diagnostic code 7615 negatively impact the ability of a fetus number.) to those diseases, it does not. to properly develop and carry to full SUPPLEMENTARY INFORMATION: VA Dysmenorrhea and secondary term. The commenter also suggested VA published a proposed rule in the amenorrhea are only examples of provide for an award of special monthly Federal Register at 80 FR 10637 on diseases that would be rated under compensation under the provisions of February 27, 2015, to amend 38 CFR diagnostic code 7615. Other § 3.350(a) for repeated miscarriages of 4.116, the portion of the VASRD dealing impairments associated with disease, an unknown etiology while on active with gynecological conditions and injury, or adhesions of the ovaries will duty. Miscarriages themselves are not

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disabilities for VA rating purposes, as higher combined evaluation. The and skin symptoms, which will now be they do not result in impairment of commenter further questioned whether evaluated separately as described in the earning capacity. See 38 CFR 4.1. The rating the manifestations separately revised note to diagnostic code 7621. proposed rating criteria provide for would constitute ‘‘pyramiding’’ under Second, VA agrees with the adequate ratings based on impairment 38 CFR 4.14. commenter that information should be in earning capacity due to service- The same commenter also indicated added to the proposed note under connected damage to reproductive that the diagnostic code 7621 to clarify how organs, which may include chronic Quantification (POP–Q) scoring system rating personnel should evaluate residuals of medical or surgical upon which proposed diagnostic code urinary and digestive symptoms complications of pregnancy incurred 7621 was based does not correlate with associated with pelvic organ prolapse. during service. Additionally, special the severity of symptoms affecting Specifically, VA is adding information monthly compensation may be multiple body systems. In addition, the to the note under diagnostic code 7621 warranted for loss or loss of use of a same commenter suggested that VA add to clarify that rating personnel should creative organ due to service-connected a note to diagnostic code 7621 to clarify separately evaluate any genitourinary, disability. See 38 CFR 3.350(a)(1). that functional impairment of other digestive, or skin symptoms under the Updating the list of presumptive body systems, including the urinary and appropriate diagnostic code(s) and conditions for veterans who have been the digestive systems, as a result of combine all evaluations with the 10 exposed to radiation, herbicides, or pelvic organ prolapse, shall be percent evaluation under diagnostic other environmental factors is beyond evaluated under the appropriate code 7621. With this clarification, VA the scope of this rulemaking, which is diagnostic codes. ensures that women with pelvic organ about the rating of conditions which Evaluations under proposed prolapse will receive adequate levels of have been service connected, not about diagnostic code 7621 were intended to compensation based on the functional which diseases should be subject to represent the average severity of impairment associated with their presumptive service connection. symptoms, including gynecological, prolapse, regardless of any anatomical Therefore, VA makes no changes based urinary, and digestive symptoms, and differences. The discussion by the on these comments. level of impairment as contemplated by commenter identified another potential The same commenter asked how the POP–Q system. Therefore, assigning approach of considering the greater powerful a diagnosis of female sexual separate ratings under proposed evaluation under either proposed arousal disorder would be as supporting diagnostic code 7621 and the diagnostic code 7621 or the appropriate evidence for military sexual trauma genitourinary or digestive systems system. Under that approach, however, (MST). This rulemaking concerns the would have violated pyramiding a veteran whose evaluation was based rating schedule in part 4, specifically 38 principles under 38 CFR 4.14 by on a diagnostic code under a different CFR 4.116, and the evaluations that VA allowing evaluations for urinary and/or body system would not be compensated assigns for physiological impairment digestive symptoms twice. See Esteban for the disabling effects of prolapse due to disorders of the gynecological v. Brown, 6 Vet. App. 259, 261–262 specific to the gynecological system. system and disorders of the breasts. The (1994). VA acknowledges, however, that The revised rule ensures that the evidentiary criteria for posttraumatic the average may not apply to all women disabling effects associated with stress disorder are listed in 38 CFR and that two women with the same multiple body systems are fully 3.304(f). Further, mental disabilities due degree of prolapse (as measured by captured. to MST are evaluated under the rating POP–Q) may experience different The same commenter also suggested schedule for mental disorders in § 4.130. disabling effects based on their VA amend VA Form 21–0960K–2, This comment is beyond the scope of anatomical size. Therefore, in order to Gynecological Conditions Disability this rulemaking. Therefore, VA makes more accurately evaluate functional Benefits Questionnaire (DBQ) to add no changes based on this comment. impairment and to ensure that the questions regarding the effects of any One commenter was supportive of the severity of the symptoms affecting diagnosed gynecological condition on overall changes and additions to this multiple body systems are fully the digestive system and consideration section of the rating schedule. However, captured, VA amends the proposed of whether the veteran has loss of use the commenter expressed concern that rating criteria and the note under of a creative organ. The commenter the proposed rating criteria for diagnostic code 7621 to include noted that the DBQ already asks the diagnostic code 7621 do not adequately guidance on how to rate the residuals examiner to comment on whether the measure disability affecting multiple and complications of pelvic organ gynecological conditions impact the body systems. Specifically, the prolapse. genitourinary system. Currently, VA commenter stated that the proposed rule First, VA amends diagnostic code Form 21–0960K–2 asks an examiner to was unclear as to whether a veteran 7621 to provide a 10 percent disability report any complications resulting from would obtain evaluations under other rating in all cases of complete or obstetrical or gynecological conditions body systems for the complications of incomplete pelvic organ prolapse due to or procedures. Additionally, VA Form pelvic organ prolapse, or whether the injury, disease, or surgical 21–0960K–2 asks the examiner if the mild, moderate, or severe rating under complications of pregnancy. This veteran has any other pertinent findings, proposed amended diagnostic code minimum level of compensation complications, conditions, signs and/or 7621 is meant to encompass all recognizes the disabling effects of the symptoms related to any conditions symptoms due to one or multiple pelvic alteration to a woman’s normal listed in the diagnosis section of the organ prolapses. The commenter stated anatomy, such as a feeling of vaginal form. Therefore, VA has an adequate that, if these manifestations in different fullness or heaviness or pressure in the mechanism to capture each and every body systems are meant to be , that are not generally included in condition related to the effects of any compensated under diagnostic code the compensable levels of disability in diagnosed gynecological condition, 7621, there is great potential for other body systems. The higher including the digestive system and loss undercompensating the veteran, as disability ratings in originally proposed of use of a creative organ. VA also notes separate ratings under the genitourinary diagnostic code 7621 took into that all affected DBQs will be updated and digestive system may afford a consideration genitourinary, digestive, upon issuance of this final rule and will

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adhere to the same principles of is unnecessary; functional impairment caused in part by decreased blood flow recording pertinent findings. Therefore, due to the colpectomy/total to the genital area and peripheral nerve VA makes no changes based on these vaginectomy is adequately addressed damage due to micro trauma or disease comments. under diagnostic code 7618 for partial process. This form of FSAD does not Lastly, the same commenter suggested and/or total hysterectomy. In rare cases, include the psychological features of VA add a separate diagnostic code in colpectomy is performed without any Female Sexual Interest/Arousal Disorder § 4.116 for loss of coital function due to form of hysterectomy; VA will evaluate outlined in DSM–5 such as lack of, or removal of the by colpectomy these circumstances analogously to significantly reduced, sexual interest or and a note to consider special monthly diagnostic code 7618, and, in the desire. If an individual is diagnosed compensation under 38 CFR 3.350(a) to absence of functional impairment or with Female Sexual Interest/Arousal increase rating consistency. VA other findings, apply the provisions of Disorder as outlined in DSM–5 that is appreciates this comment, but notes that 38 CFR 4.31 to establish service service connected, she will be rated the VASRD, in accordance with 38 CFR connection at a noncompensable rate. under the appropriate diagnostic code 4.1, is ‘‘a guide in the evaluation of This approach provides VA with under 38 CFR 4.130, which pertains to disability’’ in terms of occupational adequate criteria to evaluate functional mental disorders. Furthermore, if her impairment and is not an exhaustive list impairment associated with colpectomy, disability picture includes FSAD, of all potential diseases or conditions. with or without hysterectomy, and to defined as the continual or recurrent This is further reinforced by 38 CFR establish service connection for a inability to accomplish or maintain an 4.20, which specifically provides for disability for purposes of an award of ample lubrication-swelling reaction analogous evaluations for unlisted special monthly compensation under 38 during , then separate conditions according to closely related CFR 3.350(a). We note that while compensation under diagnostic code diseases or injuries based on function vaginal damage due to colpectomy may 7632 would be appropriate. Therefore, affected, anatomical location, and be associated with loss of coital VA makes no changes based on this symptomatology. function, coital function is not in itself comment. Colpectomy, also known as a disability for VA rating purposes. It VA appreciates the comments vaginectomy, is a surgical procedure does not result in the loss of earning submitted in response to the proposed that obliterates the vaginal canal in capacity. See 38 CFR 4.1. rule. Based on the rationale stated in the order to alleviate the symptoms of Entitlement to special monthly proposed rule and in this document, the advanced pelvic organ prolapse or to compensation for anatomical loss or loss proposed rule is adopted as a final rule treat gynecological malignancies. Such of use of a creative organ may not be with the changes noted above. obliterative procedure is reserved for awarded more than once per creative Additionally, VA notes that it is making women who are not candidates for more organ. In the case of colpectomy with a technical correction to its proposed extensive surgery or do not plan future loss of coital function, the presence or changes to Appendix B to Part 4— vaginal intercourse. Colpectomy is absence of partial/total hysterectomy Numerical Index of Disabilities. generally deemed appropriate for does not entitle a female veteran to Specifically, VA inadvertently left out elderly patients with medical additional awards of special monthly instructions to delete references to comorbidities or for patients with compensation based on further diagnostic codes 7622 and 7623 which, previous failed prolapse surgery or anatomical loss of a creative organ; in as discussed in the proposed rule, are trials who are not sexually either scenario the veteran has met the being removed. active. Evans, J., Karram, M., ‘‘Step by statutory criteria for anatomical loss or Effective Date of Final Rule step: Obliterating the vaginal canal to loss of use of the female creative organ correct pelvic organ prolapse,’’ OBG with varying degrees of functional Veterans Benefits Administration Manag. 2012 February;24(2):30–41 disability associated with the loss/loss (VBA) personnel utilize the Veterans https://www.mdedge.com/sites/default/ of use. Accordingly, establishing a Benefit Management System for Rating files/Document/September-2017/0212_ separate diagnostic code for colpectomy (VBMS–R) to process disability OBGM_Karram.pdf. Colpectomy in would not create entitlement to compensation claims that involve younger patients is performed to treat additional special monthly disability evaluations made under the advanced vaginal and/or uterine cancer. compensation under 38 CFR 3.350. For VASRD. In order to ensure that there is In cases of uterine cancer, colpectomy is these reasons, VA makes no changes no delay in processing veterans’ claims, used exclusively in conjunction with based on these comments at this time. VA must coordinate the effective date of total abdominal hysterectomy. In cases One commenter was supportive of the this final rule with corresponding of vaginal cancer, vaginectomy may be proposed addition of the new diagnostic VBMS–R system updates. As such, this partial, subtotal, or total, depending on code 7632, Female sexual arousal final rule will apply effective May 13, the extent of the disease. Vaginal disorder (FSAD). The commenter noted 2018, the date VBMS–R system updates reconstruction is offered in order to that the title used, ‘‘Female sexual related to this final rule will be preserve coital function. Bardavil, T. et arousal disorder,’’ is not the current complete. al., ‘‘Vaginal Cancer’’ (updated Jan. 11, medical term used in The Diagnostic 2015), Medscape, https:// and Statistical Manual of Mental Executive Orders 12866, 13563, and emedicine.medscape.com/article/ Disorders, Fifth Edition (DSM–5). In 13771 269188-overview#a23 (last accessed DSM–5, gender-specific sexual Executive Orders 12866 and 13563 March 8, 2018). Partial vaginectomy is dysfunctions have been added, and, for direct agencies to assess the costs and not associated with the loss of coital females, sexual desire and arousal benefits of available regulatory function. disorders have been combined into one alternatives and, when regulation is Accordingly, the vast majority of disorder: Female Sexual Interest/ necessary, to select regulatory colpectomy procedures involve Arousal Disorder. approaches that maximize net benefits associated partial or complete VA’s proposed diagnostic code 7632 (including potential economic, hysterectomy, currently addressed in differs from the DSM–5 diagnosis environmental, public health and safety diagnostic code 7618 and a new, because it only addresses the effects, and other advantages; separate diagnostic code for colpectomy physiologic form of FSAD, which is distributive impacts; and equity).

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Executive Order 13563 (Improving directly affected. Therefore, pursuant to List of Subjects in 38 CFR Part 4 Regulation and Regulatory Review) 5 U.S.C. 605(b), this rulemaking is emphasizes the importance of exempt from the initial and final Disability benefits, Pensions, quantifying both costs and benefits, regulatory flexibility analysis Veterans. reducing costs, harmonizing rules, and requirements of sections 603 and 604. Signing Authority promoting flexibility. Executive Order Unfunded Mandates 12866 (Regulatory Planning and The Secretary of Veterans Affairs, or Review) defines a ‘‘significant The Unfunded Mandates Reform Act designee, approved this document and regulatory action,’’ which requires of 1995 requires, at 2 U.S.C. 1532, that authorized the undersigned to sign and review by the Office of Management and agencies prepare an assessment of submit the document to the Office of the Budget (OMB), as ‘‘any regulatory action anticipated costs and benefits before Federal Register for publication that is likely to result in a rule that may: issuing any rule that may result in the electronically as an official document of (1) Have an annual effect on the expenditure by State, local, and tribal the Department of Veterans Affairs. economy of $100 million or more or governments, in the aggregate, or by the Jacquelyn Hayes-Byrd, Deputy Chief of adversely affect in a material way the private sector, of $100 million or more Staff, Department of Veterans Affairs, economy, a sector of the economy, (adjusted annually for inflation) in any approved this document on April 3, productivity, competition, jobs, the one year. This final rule will have no 2018, for publication. environment, public health or safety, or such effect on State, local, and tribal Dated: April 3, 2018. governments, or on the private sector. State, local, or tribal governments or Jeffrey M. Martin, communities; (2) Create a serious Paperwork Reduction Act Impact Analyst, Office of Regulation Policy inconsistency or otherwise interfere This final rule contains provisions & Management, Office of the Secretary, with an action taken or planned by constituting a collection of information Department of Veterans Affairs. another agency; (3) Materially alter the under the Paperwork Reduction Act of For the reasons set out in the budgetary impact of entitlements, 1995 (44 U.S.C. 3501–3521). preamble, VA amends 38 CFR part 4 as grants, user fees, or loan programs or the Specifically, this final rule is associated follows: rights and obligations of recipients with information collections related to thereof; or (4) Raise novel legal or policy the filing of disability benefits claims PART 4—SCHEDULE FOR RATING issues arising out of legal mandates, the (VA Form 21–526EZ) as well as DISABILITIES President’s priorities, or the principles Disability Benefits Questionnaires set forth in this Executive Order.’’ (DBQs) which enable a claimant to ■ 1. The authority citation for part 4 The economic, interagency, gather the necessary information from continues to read as follows: budgetary, legal, and policy his or her treating physician as to the Authority: 38 U.S.C. 1155, unless implications of this regulatory action current symptoms and severity of a otherwise noted. have been examined and it has been disability (VA Forms 21–0960K–1, determined not to be a significant Breast Conditions and Disorders DBQ, Subpart B—Disability Ratings regulatory action under Executive Order and 21–0960K–2, Gynecological 12866. VA’s impact analysis can be Conditions DBQ). Both information ■ 2. Amend § 4.116 as follows: found as a supporting document at collections are currently approved by ■ a. Revise the entry for diagnostic code http://www.regulations.gov, usually the Office of Management and Budget 7610; within 48 hours after the rulemaking (OMB) and have been assigned OMB ■ b. Add a note at the end of the entries document is published. Additionally, a control numbers 2900–0747 and 2900– for diagnostic codes 7615 and 7619; copy of the rulemaking and its impact 0778, respectively. VA has reviewed the ■ c. Revise the entry for diagnostic code analysis are available on VA’s website at impact of this final rule on these http://www.va.gov/orpm by following 7621; information collections and determined ■ the link for VA Regulations Published that the information collection burden is d. Remove the entries for diagnostic from FY 2004 through FYTD. This rule de minimis. codes 7622 and 7623; is not an E.O. 13771 regulatory action ■ e. Revise the entries for diagnostic because this rule is not significant under Catalog of Federal Domestic Assistance codes 7627 and 7628; E.O. 12866. The Catalog of Federal Domestic ■ f. Add entries for diagnostic codes Assistance program numbers and titles Regulatory Flexibility Act 7630 through 7632 in numerical order; for this rule are 64.009, Veterans and The Secretary hereby certifies that Medical Care Benefits; 64.104, Pension ■ g. Add an authority citation at the end this final rule will not have a significant for Non-Service-Connected Disability of the section. economic impact on a substantial for Veterans; 64.109, Veterans number of small entities as they are Compensation for Service-Connected The revisions and additions read as defined in the Regulatory Flexibility Disability; and 64.110, Veterans follows: Act, 5 U.S.C. 601–612. This final rule Dependency and Indemnity § 4.116 Schedule of ratings— will not affect any small entities. Only Compensation for Service-Connected gynecological conditions and disorders of certain VA beneficiaries could be Death. the breast.

Rating

******* 7610 Vulva or , disease or injury of (including vulvovaginitis)

******* 7615 * * *

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Rating

Note: For the purpose of VA disability evaluation, a disease, injury, or adhesions of the ovaries resulting in ovarian dys- function affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under diag- nostic code 7615

******* 7619 * * * Note: In cases of the removal of one ovary as the result of a service-connected injury or disease, with the absence or non- functioning of a second ovary unrelated to service, an evaluation of 30 percent will be assigned for the service-connected ovarian loss

******* 7621 Complete or incomplete pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy ...... 10 Note: Pelvic organ prolapse occurs when a pelvic organ such as bladder, , uterus, vagina, small bowel, or rectum drops (prolapse) from its normal place in the abdomen. Conditions associated with pelvic organ prolapse include: uterine or vaginal vault prolapse, , , , , or any combination thereof. Evaluate pelvic organ prolapse under DC 7621. Evaluate separately any genitourinary, digestive, or skin symptoms under the appropriate diag- nostic code(s) and combine all evaluations with the 10 percent evaluation under DC 7621

******* 7627 Malignant neoplasms of gynecological system ...... 100 Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. 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. Rate chronic residuals to include scars, lymphedema, dis- figurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body sys- tem 7628 Benign neoplasms of gynecological system. Rate chronic residuals to include scars, lymphedema, disfigurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body system

******* 7630 Malignant neoplasms of the breast ...... 100 Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, 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. Rate chronic residuals according to impairment of function due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code 7626 7631 Benign neoplasms of the breast and other injuries of the breast. Rate chronic residuals according to impairment of func- tion due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code 7626 7632 Female sexual arousal disorder (FSAD) ...... 1 0 1 Review for entitlement to special monthly compensation under § 3.350 of this chapter.

(Authority: 38 U.S.C. 1155) ■ b. Adding, in numerical order, entries Appendix A to Part 4—Table of ■ 3. Amend appendix A to part 4 by: for diagnostic codes 7630 through 7632. Amendments and Effective Dates Since ■ a. Revising the entries for diagnostic The revisions and additions read as 1946 codes 7610, 7615, 7619, 7621, 7622, follows: 7623, 7627, and 7628; and

Diagnostic Sec. code No.

******* 7610 Criterion May 22, 1995; title May 13, 2018.

******* 7615 Criterion May 22, 1995; note May 13, 2018.

******* 7619 Criterion May 22, 1995; note May 13, 2018.

******* 7621 Criterion May 22, 1995; evaluation May 13, 2018. 7622 Removed May 13, 2018. 7623 Removed May 13, 2018.

******* 7627 Criterion March 10, 1976; criterion May 22, 1995; title, note May 13, 2018. 7628 Added May 22, 1995; title, criterion May 13, 2018.

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Diagnostic Sec. code No.

******* 7630 Added May 13, 2018. 7631 Added May 13, 2018. 7632 Added May 13, 2018.

*******

■ 4. Amend appendix B to part 4 by: ■ c. Revising the entries for diagnostic The revisions and additions read as ■ a. Revising the entries for diagnostic codes 7627 and 7628; and follows: codes 7610 and 7621; ■ d. Adding, in numerical order, entries ■ b. Removing the entries for diagnostic Appendix B to Part 4—Numerical Index for diagnostic codes 7630 through 7632. codes 7622 and 7623; of Disabilities

Diagnostic code No.

*******

Gynecological Conditions and Disorders of the Breast

7610 ...... Vulva or clitoris, disease or injury of (including vulvovaginitis).

******* 7621 ...... Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy.

******* 7627 ...... Malignant neoplasms of gynecological system. 7628 ...... Benign neoplasms of gynecological system.

******* 7630 ...... Malignant neoplasms of the breast. 7631 ...... Benign neoplasms of the breast and other injuries of the breast. 7632 ...... Female sexual arousal disorder (FSAD).

*******

■ 5. Amend appendix C to part 4 as ■ c. Under the heading ‘‘Injury,’’ add in ■ f. Remove the entry ‘‘Pregnancy, follows: alphabetical order an entry for ‘‘Breast’’. surgical complications’’. ■ ■ a. Add in alphabetical order an entry d. Under the heading ‘‘Neoplasms: ■ g. Under the heading ‘‘Uterus,’’ Benign:’’: for ‘‘Complete or incomplete pelvic ■ i. Add in alphabetical order an entry remove the entry ‘‘Displacement’’. organ prolapse due to injury or disease for ‘‘Breast’’. ■ h. Remove ‘‘Vulva disease or injury or surgical complications of pregnancy, ■ ii. Remove ‘‘Gynecological or breast’’ of’’ and add in its place ‘‘Vulva or including uterine or vaginal vault and in its place add ‘‘Gynecological’’. clitoris, disease or injury of’’. prolapse, cystocele, urethrocele, ■ e. Under the heading ‘‘Neoplasms: The additions and revisions read as rectocele, enterocele, or combination’’. Malignant:’’: follows: ■ b. Add in alphabetical order an entry ■ i. Add in alphabetical order an entry for ‘‘Female sexual arousal disorder for ‘‘Breast’’. Appendix C to Part 4—Alphabetical ■ ii. Remove ‘‘Gynecological or breast’’ (FSAD)’’. Index of Disabilities and in its place add ‘‘Gynecological’’.

Diagnostic code No.

******* Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy, including uterine or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or combination ...... 7621

******* Female sexual arousal disorder (FSAD) ...... 7632

******* Injury:

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Diagnostic code No.

******* Breast ...... 7631

******* Neoplasms: Benign: Breast ...... 7631

******* Malignant: Breast ...... 7630

*******

[FR Doc. 2018–07081 Filed 4–6–18; 8:45 am] previously removed Missouri Incorporation by reference, BILLING CODE 8320–01–P regulations; omitted the addition of a Intergovernmental relations, Lead, previously approved regulation; and Nitrogen dioxide, Ozone, Particulate erroneously published incorrect state matter, Reporting and recordkeeping ENVIRONMENTAL PROTECTION effective dates and citation information requirements, Sulfur oxides, Volatile AGENCY for previously approved entries. organic compounds, On October 21, 2014 (79 FR 62844), Dated: March 27, 2018. 40 CFR Part 52 in a direct final rule, EPA approved a revision to ‘‘10–6.400’’. The state Karen A. Flournoy, [EPA–R07–OAR–2015–0105; FRL–9976–48– effective date is 6/27/13. Acting Regional Administrator, Region 7. Region 7] On March 3, 2015 (80 FR 11323), in Accordingly, EPA amends 40 CFR a final rule, EPA approved a revision to Approval and Promulgation of Air part 52 as set forth below: Quality Implementation Plans; remove the chapter titled ‘‘Missouri Missouri; Update to Materials Department of Public Safety, Division PART 52—APPROVAL AND Incorporated by Reference; Correcting 50-State Highway Patrol, Chapter 2— PROMULGATION OF Amendments Motor Vehicle Inspection’’ and its IMPLEMENTATION PLANS entries for ‘‘50–2.010 through 50– AGENCY: Environmental Protection 2.420’’. This final rule also approved the ■ 1. The authority citation for part 52 Agency (EPA). addition of ‘‘10–5.381’’. continues to read as follows: ACTION: Final rule; correcting On March 4, 2015 (80 FR 11577), EPA amendments. approved in a direct final rule a revision Authority: 42 U.S.C. 7401 et seq. to remove the entry for ‘‘10–5.240’’ and SUMMARY: The Environmental Protection approved revisions to Missouri Subpart AA—Missouri Agency (EPA), in a final rule action regulations ‘‘10–6.010’’, ‘‘10–6.020’’ and published in the Federal Register on ‘‘10–6.040’’. The state effective date of ■ 2. Amend § 52.1320(c) by: August 6, 2015, erroneously approved ‘‘10–6.010’’ is 7/30/14; the state ■ a. Removing the entry for ‘‘10–5.240’’; and codified previously removed effective date of ‘‘10–6.020’’ is 3/30/14; ■ b. Adding the entry for ‘‘10–5.381’’ in entries; erroneously omitted the and the state effective date of ‘‘10– numerical order; addition of previously approved entries; 6.040’’ is 11/30/14. and erroneously published codification Therefore, we are correcting the EPA’s ■ c. Revising entries ‘‘10–6.010’’, ‘‘10– of previously revised entries. This regulations to remove ‘‘10–5.240’’; add 6.020’’, ‘‘10–6.040’’, and ‘‘10–6.400’’; technical amendment corrects the ‘‘10–5.381’’; remove the chapter titled and erroneous entries. ‘‘Missouri Department of Public Safety, ■ d. Removing the heading ‘‘Missouri DATES: This rule is effective on April 9, Division 50-State Highway Patrol, Department of Public Safety, Division 2018. Chapter 2—Motor Vehicle Inspection’’ 50-State Highway Patrol, Chapter 2— and its entries for ‘‘50–2.010 through FOR FURTHER INFORMATION CONTACT: Jan Motor Vehicle Inspection’’ and the 50–2.420’’; and revise ‘‘10–6.010’’, ‘‘10– entries ‘‘50–2.010’’ through ‘‘50–2.420’’. Simpson at (913) 551–7089, or by email 6.020’’ and ‘‘10–6.040’’ to reflect the at [email protected]. most currently approved dates and The addition and revisions read as SUPPLEMENTARY INFORMATION: The citations. follows: August 6, 2015 (80 FR 46804), Federal § 52.1320 Identification of plan. Register final rule and notice of List of Subjects in 40 CFR Part 52 administrative change inadvertently and Environmental protection, Air * * * * * erroneously approved and codified pollution control, Carbon monoxide, (c) * * *

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