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37594 Proposed Rules Federal Register Vol. 84, No. 148 Thursday, August 1, 2019 This section of the FEDERAL REGISTER Room 1068, between the hours of 8:00 (b)(3), and (c), and redesignate contains notices to the public of the proposed a.m. and 4:30 p.m. Monday through paragraphs (b)(4) as (b)(2) of this issuance of rules and regulations. The Friday (except holidays). Please call section. purpose of these notices is to give interested (202) 461–4902 for an appointment. II. General Rating Formula for Diseases persons an opportunity to participate in the (This is not a toll-free number.) In rule making prior to the adoption of the final of the Heart rules. addition, during the comment period, please view comments online through VA proposes to revise § 4.104 to the Federal Docket Management System include a new General Rating Formula DEPARTMENT OF VETERANS (FDMS) at www.Regulations.gov. for Diseases of the Heart (General AFFAIRS FOR FURTHER INFORMATION CONTACT: Gary Formula). VA will use this new General Reynolds, MD, Medical Officer, Formula to clarify and standardize the 38 CFR Part 4 Regulations Staff (211D), Compensation evaluation of many cardiovascular diseases. As discussed below, it will RIN 2900–AQ67 Service, Veterans Benefits Administration, Department of Veterans provide a more timely, efficient, and accurate method of evaluating these Schedule for Rating Disabilities: The Affairs, 810 Vermont Avenue NW, diseases. Cardiovascular System Washington, DC 20420, (202) 461–9700. (This is not a toll-free telephone The proposed General Formula AGENCY: Department of Veterans Affairs. number.) reflects current concepts in ACTION: Proposed rule. cardiovascular disability. The Institute SUPPLEMENTARY INFORMATION: As part of of Medicine (now called the National VA’s ongoing revision of the VA SUMMARY: The Department of Veterans Academy of Medicine) stated, ‘‘It is Affairs (VA) proposes to amend the Schedule for Rating Disabilities (VASRD important for the Rating Schedule to be section of the VA Schedule for Rating or Rating Schedule), VA proposes as up-to-date as possible in current Disabilities (VASRD or Rating Schedule) changes to 38 Code of Federal medical approaches and terminology to that addresses the cardiovascular Regulations (CFR) §§ 4.100 and 4.104, serve veterans with disabilities most which pertain to the cardiovascular system. The proposed changes effectively. This ensures that the criteria system. The proposed changes will: (1) incorporate medical advances that have in the Rating Schedule are based on Update the medical terminology of occurred since the last review, update concepts and terms used by medical certain conditions; (2) add medical medical terminology, and clarify personnel who provide medical conditions not currently in the Rating evaluation criteria where necessary. evidence, and that evolving Where changes to the scientific and/ Schedule; (3) refine evaluation criteria understanding of, or recognition of, new or medical nature of a given condition based on medical advances that have disabling conditions are reflected.’’ have been proposed, VA has cited the occurred since the last revision; and (4) Institute of Medicine, Committee on published, publicly-available sources incorporate current understanding of Medical Evaluation of Veterans for for these changes. The proposed functional changes associated with, or Disability Compensation, ‘‘A 21st changes are not a reflection of any resulting from, cardiovascular disease or Century System for Evaluating Veterans particular expert’s comments or injury (pathophysiology). for Disability Benefits,’’ 5 (Michael recommendations, but were based on I. § 4.100 Application of the McGeary et al. eds. 2007). published, peer-reviewed materials. Evaluation Criteria for Diagnostic As in the current Rating Schedule, the Materials from the public forum, held in Codes 7000–7007, 7011, and 7015–7020 proposed General Formula is based 2011, are available for public inspection primarily on Metabolic equivalents In almost all cases, the current § 4.100 (METs), which objectively and at the Office of Regulation Policy and specifically requires testing for Management (see the ADDRESSES section accurately measure the cardiac work metabolic equivalent of tasks when capacity and which clinicians routinely of this rulemaking), and other evaluating heart diseases. Medical deliberative materials are cited herein. obtain for all patients with heart literature more commonly refers to disease. The examiner eliminates DATES: VA must receive comments on or metabolic equivalent of tasks as simply spurious results by considering various before September 30, 2019. metabolic equivalents, or METs. parameters, such as age and expected ADDRESSES: Submit written comments Exceptions to METs testing for rating maximal heart rate achieved when through www.Regulations.gov; by mail purposes occur when medically factors other than heart disease are or hand-delivery to the Director, Office contraindicated, when the left ejection present. In situations where a person is of Regulations Policy and Management fraction is 50 percent or less, with unable to walk, or walk well, the patient (00REG), Department of Veterans chronic congestive heart failure, when may test on a bicycle or with the use of Affairs, 810 Vermont Ave. NW, Room more than one episode of heart failure certain medications. 1064, Washington, DC 20420; or by fax occurred in the past year, or when VA VA notes that a number of diagnostic to (202) 273–9026. Comments should may assign a 100 percent evaluation on codes (DCs) within current § 4.104, indicate that they are submitted in another basis. 38 CFR 4.100(b). As including DCs 7000–7007, 7011, 7015– response to RIN 2900–AQ67—Schedule explained below, this proposed rule will 7017, and 7019–7020, already utilize for Rating Disabilities: The eliminate considering ejection fractions METs in evaluating their respective Cardiovascular System. Copies of or congestive heart failure when cardiovascular conditions. Specifically, comments received will be available for evaluating cardiovascular disability. each level of evaluation (10, 30, 60, and public inspection in the Office of Therefore, for clarity and simplicity, VA 100 percent) outlines a range of METs, Regulation Policy and Management, proposes to delete paragraphs (b)(2), as well as a list of associated symptoms, VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 PO 00000 Frm 00001 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 jspears on DSK3GMQ082PROD with PROPOSALS Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules 37595 within which an individual must fall to purposes, METs (metabolic equivalent § 4.14 (pyramiding). VA will provide an warrant that particular evaluation. of tasks) for cardiac energy. instruction immediately before DC 7009 Additionally, VA may assign higher In evaluating cardiovascular which states ‘‘For DCs 7009, 7010, 7011, ratings (e.g., 60 and 100 percent) for disabilities, METs refer to the intensity and 7015, a single evaluation will be congestive heart failure or left of activities. For example, an activity assigned under the diagnostic code ventricular dysfunction as demonstrated with a MET of 2, such as walking at a which reflects the predominant by ejection fraction. Finally, VA may slow pace (e.g., 2 mph), would require disability picture.’’ also assign a 30 percent evaluation with twice the energy that an average person The discussion that follows explains evidence on electrocardiogram, consumes at rest (e.g., sitting quietly), the changes to each DC affected by the echocardiogram, or X-ray of cardiac which requires 1 MET. See ‘‘The General Formula, and explains hypertrophy or dilatation. Lastly, VA Compendium of Physical Activities,’’ additional changes to these DCs (e.g., may assign a 10 percent evaluation if Arnold School of Public Health- title changes, note changes, etc.). Prevention Research Center, available at the condition requires continuous A. Diagnostic Code 7000 medication. http://prevention.sph.sc.edu/tools/ VA proposes to rely on METs as the compendium.htm. VA does not propose DC 7000 currently provides a 100 primary indicator of cardiac ability and any alteration to the ranges of METs percent evaluation during active eliminate other indicators currently provided in the current VASRD, nor infection with valvular heart damage found in the VASRD, such as ejection will it eliminate the references to and for three months following the fractions or the number of any episodes dyspnea, fatigue, angina, dizziness, or cessation of treatment for the active of acute congestive heart failure in the syncope. Instead, VA proposes to state infection. VA proposes no change to this past year. These latter indicators are less that these symptoms may represent provision. Following the three months, reliable in assessing cardiac function. heart failure. VA also proposes to use VA will evaluate residual cardiac Congestive heart failure may be due to the more common term disability using the General Rating poor conditioning, salt consumption, ‘‘breathlessness’’ for the more obscure Formula for Diseases of the Heart. term ‘‘dyspnea,’’ and to expand the list poor medication compliance, body B. Diagnostic Codes 7001 and 7002 weight, additional disease burden, or a of common findings associated with The current DCs 7001 and 7002 variety of other factors not associated congestive heart failure to include (endocarditis and pericarditis, with the underlying cardiovascular arrhythmia and palpitations.
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