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,

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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. See ‘‘Congestive Heart Failure,’’ Johns respectively) provide a 100 percent disease itself. See Joshi, Mohanan et al., Hopkins Medicine, available at http:// evaluation during active infection with ‘‘Factors precipitating Congestive Heart www.hopkinsmedicine.org/heart_ cardiac involvement, and for three Failure—role of patient non- vascular_institute/conditions_ months following the cessation of compliance,’’ 47 J. Assoc. Physicians treatments/conditions/congestive_ treatment for the active infection. VA India 294–95 (Mar. 1999) (emphasizing heart_failure.html (last visited Apr. 30, proposes no change to these provisions. ‘‘the importance of patient non- 2014). Although VA proposes to Following the three months, VA will compliance with prescribed therapy as eliminate the use of congestive heart evaluate any residual cardiac disability a leading precipitating factor for failure and ejection fraction as using the General Rating Formula for congestive heart failure . . . which can indicators for evaluation, it will retain Diseases of the Heart. be prevented by appropriate cost saving the non-MET criteria provided in the strategies aimed to improve patient current 10 and 30 percent evaluations C. Diagnostic Codes 7003, 7004, 7005, compliance.’’) Similarly, ejection because these criteria remain valid. Id. 7007, and 7020 fractions are unreliable because factors VA proposes to apply the General VA proposes to evaluate disability unrelated to cardiovascular disability, Formula to those DCs within § 4.104 due to these conditions (pericardial such as fluid intake, salt ingestion, and that instruct rating personnel to adhesions, syphilitic heart disease, exercise, may influence them. See consider METs (among other arteriosclerotic heart disease, Ramachandran S. Vasan, MD, et al., indicators). The DCs using METS as the hypertensive heart disease, and ‘‘Congestive heart failure in subjects primary rating criteria include 7003, cardiomyopathy, respectively) using the with normal versus reduced left 7004, 7005, 7007, 7015, and 7020. On General Rating Formula. ventricular ejection fraction,’’ 33(7) the other hand, DCs 7000, 7001, 7002, 1948–55 (1999). Conversely, METs form 7006, 7011, 7016, 7017, and 7019 have D. Diagnostic Code 7006 the most reliable basis of cardiac 100 percent evaluation criteria unique The current DC 7006 provides a 100 capability, even after heart disease to each particular DC. VA does not percent evaluation during, and for three weakens the ability of the heart to intend to disturb the 100 percent months following, a documented function at full capacity. See Charles K. evaluations currently prescribed in myocardial infarction. VA proposes no Morris, MD, et al., ‘‘Nomogram based on these DCs; rather, it proposes to apply change to this provision. Following the metabolic equivalents and age for the General Formula following the total three months, VA proposes to evaluate assessing aerobic exercise capacity in evaluations. To ensure clarity and residual disability under the General men,’’ 22(1) J. Am. College of consistency in applying the General Rating Formula. Cardiology, 175–82 (1993). Formula, VA intends to instruct The heart is often described as the personnel to rate disabilities under E. Diagnostic Code 7011 pump of the human body, and, as such, § 4.104 using the General Formula VA does not propose any change to requires power to function. Power is the unless otherwise directed. the current DC 7011 provisions rate that energy is consumed to work. With respect to DCs 7010, 7011, 7015, establishing a 100 percent evaluation for Various types of energy employ and newly proposed DC 7009, sustained ventricular arrhythmia or different measures of rate (power), such regardless of the DC, the resulting ventricular aneurysmectomy from the as kW (kilowatts) for electrical energy; impairment and disability are date of hospital admission. However, Btu/hr (British Thermal Units per hour) essentially indistinguishable. To offer VA proposes to apply the General for heat energy; hp (horsepower) for more than one evaluation under those Rating Formula following the mechanical energy; and, for our circumstances would be contrary to mandatory examination provided six

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months after discharge to determine the ventricles, which may result in I. Diagnostic Code 7019 residual disability rating. symptoms of dizziness, light- Currently, DC 7019 provides a 100 Additionally, DC 7011 currently headedness, or syncope. In addition, percent evaluation from the date of includes a note indicating VA will individuals with second degree may conduct a mandatory examination six hospital admission for cardiac experience chest pain, hypoperfusion, transplantation, continuing for ‘‘an months following discharge and therapy and hypotension. Ali A. Sovari, for a sustained arrhythmia or ventricular indefinite period.’’ The current note also ‘‘Second-Degree Atrioventricular Block states, however, that one year following aneurysmectomy. The intent is to Clinical Presentation,’’ Medscape— monitor the extent of disability discharge, VA should examine the Reference (May 9, 2013), http:// individual to determine the appropriate following inpatient hospitalization for emedicine.medscape.com/article/ surgical intervention and therapy. VA disability rating, assigning a minimum 161919-clinical (last visited April 22, proposes to add the phrase ‘‘discharge evaluation of 30 percent. VA applies 38 2014). Second-degree type II presents a from inpatient hospitalization’’ to the CFR 3.105(e) to any change in note to clarify that the timing for much more immediate medical risk as it evaluation. VA proposes no changes to mandatory re-examination is based may progress rapidly to complete heart this process or the minimum evaluation upon discharge from inpatient block. As a result, affected individuals of 30 percent. However, VA proposes to hospitalization, rather than discharge may receive permanent pacemakers. eliminate the phrase ‘‘for an indefinite from an outpatient treatment program. Third-degree heart block occurs when period’’ and replace it with ‘‘for a This proposed clarification does not none of the heart’s electrical signals minimum of one year.’’ This will represent a change in VA policy. reach the ventricles, which often eliminate any confusion as to whether requires emergency treatment because it the Veteran’s 100 percent evaluation F. Diagnostic Code 7015 can result in cardiac arrest or death. may be subject to reduction during the VA proposes to update this DC to Like second-degree type II, this severe year following transplantation. reflect modern treatment and to more type of atrioventricular block requires Practically, a Veteran will receive a 100 accurately evaluate impairment by pacemaker implantation. Based on this percent evaluation for at least one year separating the various forms of treatment, VA proposes to evaluate the plus hospitalization time as VA will not atrioventricular block into two specific non-benign categories of atrioventricular re-evaluate the Veteran until one year categories: benign and non-benign i.e., block (second-degree, type II and third- following hospital discharge. In the latter requiring immediate degree) under DC 7018, implantable addition to this change, VA proposes to treatment. ‘‘Types of Heart Block,’’ cardiac pacemakers. Given the proposed evaluate residual cardiac disability National Heart, Lung, and Blood amendments to DC 7015, the note that under the General Rating Formula. Institute (July 9, 2012), http:// currently follows is no longer relevant. Additionally, DC 7019 currently www.nhlbi.nih.gov/health/health- The VA proposes to remove the note includes a note indicating VA will topics/topics/hb/types.html (last visited following DC 7015. examine this disability one year April 22, 2014). following discharge. The note’s intent is The benign, or less severe, category of G. Diagnostic Code 7016 to assess the extent of residual cardiac atrioventricular block includes first- VA does not propose any change to disability following hospitalization for degree heart block (first-degree) and surgery. VA proposes to add the phrase second-degree heart block, type I the current DC 7016 provisions establishing a 100 percent evaluation for ‘‘discharge from inpatient (second-degree type I). First-degree hospitalization’’ to clarify when the heart valve replacement (prosthesis). (seen as a delayed or prolonged P–R point at which the timing for mandatory However, VA proposes to apply the interval on electrocardiogram), involves examination begins. Discharge from an General Rating Formula following the the slowing of the heart’s electrical outpatient treatment program does not mandatory examination provided six signals, often without any symptoms activate this provision. This clarification months after discharge to determine and, therefore, without requiring any does not represent a change in VA treatment. Id. In second-degree type I, residual disability rating. policy. the electrical signals are slowed more Additionally, DC 7016 currently and more with each heartbeat until the includes a note indicating VA will III. Proposed Changes to Diagnostic heart eventually skips a beat. An examine this disability six months Codes Not Rated Under the General occasional, transitory, and mild following discharge. The intent is to Formula symptom may be associated with monitor the extent of the disability A. Diagnostic Code 7008 second-degree type I heart block. Id. No following hospitalization for surgery. The DC 7008 addresses hyperthyroid specific therapy is required for second- Similar to DC 7011, VA proposes to link heart disease. This DC was amended degree type I heart block. Ali A. Sovari, the evaluation with discharge from with the final publication of 82 FR ‘‘Second-Degree Atrioventricular Block inpatient hospitalization for this 50804, Schedule for Rating Disabilities; Treatment & Management,’’ Medscape— particular dysrhythmia. This The Endocrine System, effective Reference (May 9, 2013) http:// clarification does not represent a change emedicine.medscape.com/article/ December 10, 2017. VA’s update of the in VA policy. 161919-treatment (last visited April 22, endocrine system (38 CFR 4.117) 2014). VA proposes to evaluate the H. Diagnostic Code 7017 revised the evaluation criteria for benign form of atrioventricular block hyperthyroidism under DC 7900. See under the General Rating Formula. DC 7017 currently provides a 100 RIN 2900–AO44. Specifically, VA The non-benign, or more severe, percent evaluation for three months eliminated any current rating criteria in category of atrioventricular block following hospital admission for DC 7900 that referred to cardiovascular include second-degree heart block, type coronary bypass surgery. VA proposes findings. Instead, VA evaluates any II (second-degree type II) and third- no change to this provision. Following hyperthyroid heart disease under DC degree heart block (third-degree). In the three months, VA proposes to 7008, which directs rating personnel to second-degree type II, some of the evaluate any residual cardiac disability evaluate any cardiovascular findings heart’s electrical signals do not reach under the General Rating Formula. according to the appropriate DC. The

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VA does not propose any additional incidentally by an ECG or Holter Surgical techniques for cardiac changes for DC 7008 at this time. monitor without any other findings. Id. pacemakers have changed and improved Therefore, the mere presence of drastically over the past several years B. Diagnostic Code 7010 episodes of supraventricular and recovery currently requires less VA proposes to change the name of tachycardia, as well as their number, is than 30 days. According to the National the current DC 7010 from unrelated to symptomatology or Institutes of Health (NIH), supraventricular arrhythmias to the disability. hospitalization following surgical more modern and accurate However, some episodes of implantation of a pacemaker usually supraventricular tachycardia. supraventricular tachycardia result in lasts one to two days. ‘‘What to Expect Arrhythmia generally refers to an hypotension, shortness of breath, After Pacemaker Surgery,’’ NIH— irregular heartbeat and includes a dizziness, or chest pain in patients who National Heart, Lung, and Blood heartbeat that is too fast, too slow, or are older or have underlying cardiac Institute (February 28, 2012), http:// irregular. ‘‘What Is an Arrhythmia?’’ disorders. Id. These symptomatic www.nhlbi.nih.gov/health/health- National Heart, Lung, and Blood episodes typically require a controlled topics/topics/pace/after.html (last Institute (July 1, 2011), http:// medical setting to monitor and treat visited April 14, 2014). NIH also www.nhlbi.nih.gov/health/health- heart rate control, anticoagulation, indicates that mild pain, swelling, and topics/topics/arr/ (last visited April 22, cardioversion, electrophysiological tenderness at the site of pacemaker 2014). Supraventricular tachycardia is studies, or catheter-based arrhythmia implantation may continue from a few an irregularly fast heartbeat that ablation. Id. Medical intervention for days to a few weeks. Id. While originates above or within the supraventricular tachycardia more healthcare providers may instruct atrioventricular node18 or in the upper accurately indicates impairment, as the patients to avoid vigorous activity, part of the heart. Id. The various forms purpose of treatment is to eliminate or including heavy lifting, for up to one of supraventricular tachycardia include, reduce any disabling symptoms. As month following surgery, most patients but are not limited to, atrial fibrillation, mentioned previously, the mere may return to their normal activity level atrial flutter, sinus tachycardia, documentation of supraventricular within a few days. Id. VA proposes to sinoatrial nodal reentrant tachycardia, tachycardia on an ECG or Holter reduce the period of 100 percent atrioventricular nodal reentrant monitor does not confirm the existence evaluation from two months to one tachycardia, atrioventricular reentrant of symptoms or impairment. month. Additionally, VA proposes to tachycardia, atrial tachycardia, As such, VA proposes to replace the add a second note to this DC, cross- junctional tachycardia, and multifocal current reference to episodes referencing DC 7009, which will be atrial tachycardia. Id. VA proposes to documented by ECG or Holter monitor addressed in greater detail below. VA add an explanatory Note 1 to provide a in DC 7010 with treatment proposes no other changes to this DC. non-exhaustive list of examples of interventions. For the purposes of this supraventricular tachycardia. VA DC, a treatment intervention occurs D. Diagnostic Code 7110 proposes to use tachycardia, rather than whenever a symptomatic patient The current DC 7110 addresses arrhythmia, in the title to clarify that requires intravenous pharmacologic impairment due to aortic aneurysm. VA rating personnel should use this DC to adjustment, cardioversion, and/or proposes to change the name of the code evaluate individuals with abnormally ablation for symptom relief. For clarity, to ‘‘Aortic aneurysm: ascending, fast heartbeats. VA proposes to add Note 2 to identify thoracic, or abdominal’’ to clarify the VA also proposes to update the when a treatment occurs. VA will assign location of aortic aneurysm that this DC evaluation criteria for supraventricular a 10 percent evaluation for will evaluate. tachycardia, utilizing hospitalization as supraventricular tachycardia, VA proposes to eliminate the 60 a more accurate measure of disability. documented by ECG, with one to four percent evaluation for an aortic The current criteria in DC 7010 assign treatment interventions per year; VA aneurysm that precludes exertion while evaluations based on the number of will assign a 30 percent evaluation with expanding the criteria for a 100 percent episodes of supraventricular five or more treatment interventions per evaluation to include symptomatic arrhythmias documented by year. VA proposes the number of aneurysm (e.g., precludes exertion). VA electrocardiogram (ECG or EKG) or interventions annually because benign, proposes to omit the 60 percent category Holter monitor, without considering the non-disabling episodes may occur as it is does not provide an adequate need for hospital treatment. throughout the year. However, only evaluation for a symptomatic aneurysm Supraventricular tachycardia is usually episodes that require treatment in which exertion may hasten rupture. non-lethal and does not result in interventions are most likely disabling, See Emile R. Mohler III, MD, ‘‘Patient disabling symptoms in otherwise because they require treatment within a information: Abdominal aortic healthy individuals. See ‘‘Paroxysmal controlled medical setting and typically aneurysm (Beyond the Basics),’’ Up-to- supraventricular tachycardia’’ in prevent an individual from working. date (Aug. 21, 2013), http:// ‘‘A.D.A.M. Medical Encyclopedia,’’ www.uptodate.com/contents/ PubMed Health, U.S. National Library of C. Diagnostic Code 7018 abdominal-aortic-aneurysm-beyond-the- Medicine (June 18, 2012), http:// DC 7018 currently provides a 100 basics#H4 (last visited May 2, 2014). A www.nlm.nih.gov/medlineplus/ency/ percent evaluation for two months symptomatic aneurysm presents a article/000183.htm (last visited Apr. 30, following hospital admission for medical emergency and requires 2014). For example, some patients with implantation or reimplantation of a surgical treatment to prevent the supraventricular tachycardias have cardiac pacemaker. Following these two aneurysm from rupturing. Id. Under the many short episodes throughout the day months, VA evaluates the disability proposed criteria, VA will grant a total and remain asymptomatic. Id. Others under DC 7010, 7011, or 7015, with a evaluation when a patient becomes a may have atrial fibrillation on a minimum evaluation of 10 percent. surgical candidate and is unable to exert permanent basis, also without Advances in surgical methods and him/herself. symptoms. These non-disabling medical technology have drastically Additionally, if a person cannot exert episodes do not require hospitalization reduced the recovery time following him/herself due to aortic aneurysm but or treatment, but may be recorded implantation of a cardiac pacemaker. is unable to undergo surgery due to a co-

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morbid medical condition (e.g., kidney surgical correction but, due to co- changes related to these criteria and dysfunction requiring dialysis), VA will morbid medical conditions or other notes. grant a total evaluation. Jeffrey Jim, MD reasons, cannot undergo surgical F. Diagnostic Code 7113 and Robert W. Thompson, MD, procedures. ‘‘Management of symptomatic (non- DC 7113, arteriovenous (AV) fistula, E. Diagnostic Code 7111 ruptured) and ruptured abdominal traumatic, currently includes the phrase aortic aneurysm,’’ UpToDate (Feb. 12, The current DC 7111 provides 100 ‘‘with edema’’ as one of the disabling 2013), http://www.uptodate.com/ percent evaluations for aneurysms of symptoms present at the 50, 40, 30, and contents/management-of-symptomatic- large arteries which are symptomatic. It 20 percent levels. However, such non-ruptured-and-ruptured-abdominal- also provides 100 percent evaluations wording does not distinguish between aortic-aneurysm?source=see_ for indefinite periods of time from the chronic and transitory edema, resulting link&anchor=H53322839#H53322839 date of hospital admission for surgical in evaluations that may be based on (last visited May 5, 2014). ‘‘Although corrections. VA proposes to amend the symptoms that are unrelated to there are rare reports of patient survival latter criteria to provide a 100 percent arteriovenous fistula or do not following ruptured abdominal aortic evaluation from the date a physician adequately represent its chronic aneurysm (AAA) without repair, in recommends surgical correction, rather residual disability. Transitory edema general, expectant management of than the date of hospital admission. may occur following prolonged ruptured AAA is nearly uniformly fatal. Aneurysms of any large artery are standing, prolonged sitting during Thus, when ruptured AAA is identified, known to spontaneously rupture, travel, the wearing of tight hosiery, repair should be undertaken emergently which, depending on its location, can taking certain medications, consuming to give the patient the best chance for lead to death if not immediately excessive salt, or being pregnant. survival.’’ Id. As such, expanding the addressed by surgery. Transitory edema due to these causes is non-disabling and typically resolves 100 percent evaluation to the date a This expansion to the 100 percent without complication. physician recommended surgical evaluation criteria requires that VA However, edema due to an AV fistula correction will include Veterans who amend the note in DC 7111. Currently, requires medical treatment and may have severely disabling aneurysms but, VA assigns the 100 percent rating as of impair function. Therefore, VA proposes due to co-morbid medical conditions or the date of admission for surgical to clarify that evaluations at the 50, 40, other reasons, cannot undergo surgical correction, and VA assesses any residual 30, and 20 percent levels under DC 7113 intervention. This 100 percent disability by a mandatory examination must involve ‘‘chronic edema’’ to better evaluation will continue for six months six months following discharge. VA comply with 38 CFR 4.1, which states following hospital discharge. proposes to add the phrase ‘‘discharge In addition, VA proposes to add a 0 the accurate application of the VASRD from inpatient hospitalization’’ in the percent rating if an aneurysm is present requires an emphasis upon ‘‘the criteria note to clarify that the timing for but does not meet the requirements for limitation of activity imposed by the the mandatory re-examination is based surgical correction. Asymptomatic disabling condition.’’ upon discharge from inpatient aneurysms may expand rapidly until hospitalization. Additionally, VA G. Diagnostic Code 7114 they require surgical correction, so they proposes to clarify that it shall assign need close medical follow-up. This The current DC 7114, titled the 100 percent evaluation beginning provision allowing service connection ‘‘Arteriosclerosis obliterans,’’ addresses for aneurysms not requiring surgery from the date a physician recommends impairment of the lower extremities due eliminates barriers to frequent medical surgical correction, in the event to narrowing and hardening of the check-ups by VA to monitor the individuals who require surgical arteries. The term ‘‘arteriosclerosis’’ is progress of those aneurysms. correction cannot undergo it due to co- also used in current note (2). VA VA will also add a directive for raters morbid medical conditions or other proposes to replace the term to evaluate non-cardiovascular residuals reasons. The 100 percent evaluation ‘‘arteriosclerosis obliterans’’ with according to the body systems affected. shall continue for six months following ‘‘peripheral arterial disease’’ to conform This is done to take into acount any hospital discharge for surgical to current medical terminology. Peter disabling residuals related to surgical correction. Libby et al., ‘‘Braunwald’s Heart correction (e.g., infection, bowel The current DC 7111 provides rating Disease: A Textbook of Cardiovascular adhesions, kidney failure, and so forth). criteria following surgical intervention Medicine,’’ 1491–1515 (8th ed. 2007). The current DC 7110 also includes a that is based on the ankle-brachial The evaluation criteria of the current note indicating that VA will assign the index, claudication on walking certain DC 7114 include the ankle/brachial 100 percent rating as of the date of distances, and other symptoms related index (ABI), associated examination admission for surgical correction. VA to poor blood flow to the extremities. findings and symptoms, or claudication will re-evaluate the condition after a These criteria provide for evaluations (pain in the extremities) upon walking mandatory examination six months ranging from 20 to 100 percent; notes (1) certain distances. The current criteria, following discharge. VA proposes to add and (2) provide additional information however, have two major shortcomings: the phrase ‘‘discharge from inpatient when evaluating post-surgical large (1) They do not account for veterans hospitalization’’ to clarify that the artery aneurysms. The residual with non-compressible arteries (these starting point to calculate the mandatory disabilities after post-surgical repair of veterans have either a normal or re-examination begins with discharge large artery aneurysms are similar to elevated ABI, which would be non- from inpatient hospitalization. VA also those under DC 7114. For greater ease of compensable); and (2) they rely in large proposes to clarify in the rating criteria use and simplicity, VA therefore part on claudication, which is an for a 100 percent evaluation that it shall proposes to remove these criteria and inconsistent measure of disability. To assign the 100 percent evaluation as of notes and replace them with that end, VA will employ a more the date a physician recommends instructions to evaluate post-surgical objective approach as outlined below. surgical correction. This practice will residuals under DC 7114. The section of VA will create evaluation criteria allow VA to assign 100 percent the preamble below specifically based on a modified version of the evaluations to individuals who require addressing DC 7114 discusses any ischemia scoring table found in J. Mills,

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‘‘The Society for Vascular Surgery arteries, veins, and nerves of the arms, (primary Raynaud’s phenomenon) Lower Extremity Threatened Limb legs, and rarely elsewhere. See Topol, should be rated under DC 7124. Classification System: Risk stratification E.J., Textbook of Cardiovascular As stated, Raynaud’s syndrome based on Wound, Ischemia, and foot Medicine Chap. 108, Pg 1535. (2007). (secondary Raynaud’s phenomenon) Infection (WIfI)’’ J Vasc Surg; vol 59, pg DC 7115 currently evaluates impairment and Raynaud’s disease (primary 226. 2014. This table uses the ABI, as of the lower extremity using the ankle/ Raynaud’s phenomenon) are unrelated well as ankle pressure (AP), toe pressure brachial index (ABI) or associated signs in both etiology and severity. According (TP) and transcutaneous oximetry and symptoms upon examination (as to the NIH’s National Heart, Lung, and (TcPO2) to describe four different levels found in current DC 7114). For the Blood Institute, Raynaud’s syndrome of impairment. The ABI is the ratio of reasons discussed above in DC 7114, VA (secondary Raynaud’s phenomenon) is the systolic blood pressure measured at proposes to clarify the evaluation typically caused by autoimmune the ankle to that measured at the criteria by using objective signs, with diseases such as scleroderma, lupus, antecubital fossa. For VA disability the ABI as the primary criteria for the rheumatoid arthritis, atherosclerosis, or compensation purposes, normal is lower extremities. VA proposes to delete polycythemia. ‘‘Raynaud Phenomenon.’’ greater than or equal to 0.80. The reason claudication on walking from all Medscape (September 6, 2017), http:// this normal value is used, rather than evaluation criteria as it inaccurately emedicine.medscape.com/article/ normal values cited in the 2016 ACC/ measures the extent of this disability. 331197-overview (last visited September AHA Guidelines is that an ABI between VA also proposes to remove current 12, 2017). 0.90 and 0.81 is not consistently Note (1), as DC 7115 will now direct On the other hand. the cause of associated with objective signs of rating personnel to evaluate lower Raynaud’s disease (primary Raynaud’s disability beyond symptomatic extremities under DC 7114 and the phenomenon) is not known. Id. complaints (e.g., wounds or infections). information regarding the ABI is Raynaud’s disease (primary Raynaud’s The AP is the systolic blood pressure contained in that diagnostic code. With phenomenon) is more common and measured at the ankle. Normal is greater elimination of current Note (1), VA tends to be less severe than Raynaud’s than or equal to 100 mm Hg. The TP is proposes to rename existing Note (2) as syndrome (secondary Raynaud’s the systolic blood pressure measured at Note (1) with clarification similar to that phenomenon). Ray W. Gifford, Jr. & the great toe. Normal is greater than or proposed in Note (3) DC 7114 (as Edgar A. Hines, Jr., ‘‘Raynaud’s Disease equal to 60 mm Hg. TcPO2 is measured explained above). Additionally, a new Among Women and Girls,’’ 16 at the first intercostal space on the foot. Note (2) is proposed to give raters Circulation 1012, 1019 (1957). VA Normal is greater than or equal to 60 examples of trophic changes so it will discusses how to properly evaluate mm Hg. See also M. Kalani be easier to recognize when encountered Raynaud’s disease (primary Raynaud’s ‘‘Transcutaneous Oxygen Tension and in clinical documentation. phenomenon) below in the section Toe Blood Pressure as Predictors for proposing the new DC 7124. No other I. Diagnostic Code 7117 Outcome of Diabetic Foot Ulcers,’’ changes are proposed to DC 7117. Diabetes Care, vol. 22, Pgs 147–52. 1999. Currently, DC 7117 addresses J. Diagnostic Code 7120 The levels of impairment as described impairment due to Raynaud’s in the previously referenced ischemia syndrome, in which cold or stress DC 7121 currently evaluates post- scoring table directly correlate to levels abnormally reduces blood flow in the phlebitic syndrome of any etiology, with of disability (i.e., evaluation levels). VA extremities. Raynaud’s syndrome (also its rating criteria identical to that used will slightly modify this table to called secondary Raynaud’s in DC 7120, Varicose veins. VA describe four levels of disability (and phenomenon) is often confused with currently maintains separate DCs for thus, evaluation levels) consistent with Raynaud’s disease (also called primary these disabilities to monitor in the these criteria, while preserving the 20, Raynaud’s phenomenon or primary Veteran population the incidence and 40, 60, and 100 percent evaluation Raynaud’s), which is different in terms outcome of claims for these specific and levels. of etiology and severity. While both separate diagnoses. However, for clarity, Turning to the three notes associated conditions present with vasospasm, consistency, and improved ease of use, with DC 7114, VA will make two Raynaud’s disease (primary Raynaud’s VA proposes to delete the duplicative significant revisions. First, VA will phenomenon) has few, if any, long term rating criteria and instruct rating revise Note (1) to add definitions and residuals. In contrast, Raynaud’s personnel to evaluate DC 7120, Varicose normal values for ABI, AP, TP, and syndrome (secondary Raynaud’s veins, under DC 7121, Post-phlebitic TcPO2. Next, VA will redesignate phenomenon) is associated with another syndrome. VA does not propose any current Note (2) as Note (3), and current illness, most commonly an autoimmune changes to the content of DC 7121 itself. Note (3) as Note (4). Finally, VA will disease. The residuals tend to be then add a new Note (2), which directs permanent, more extensive, and more K. Diagnostic Code 7122 the rater to select the value (ABI, AP, disabling. To improve clarity, ensure VA last amended the rating criteria for TP, or TcPO2) which yields the highest more accurate evaluations, and promote DC 7122, Cold injury residuals, in 1998. level of impairment for evaluation. consistency and usability of the VASRD, 63 FR 37778. In the time since, VA proposes to focus DC 7117 on medicine has documented new chronic H. Diagnostic Code 7115 Raynaud’s syndrome (secondary residuals of cold injury. Therefore, VA DC 7115 currently uses lower Raynaud’s phenomenon) only, while proposes to update the criteria to extremity findings to evaluate thrombo- creating a new DC 7124 for Raynaud’s include the findings specifically noted angiitis obliterans (Buerger’s Disease). disease (primary Raynaud’s by the Veterans Health Initiative, VA proposes new criteria for the phenomenon or primary Raynaud’s). In Department of Veterans Affairs, ‘‘Cold evaluation of upper extremity disease addition, VA proposes to use the Injury: Diagnosis and Management of because Buerger’s Disease can affect existing note to emphasize that DC 7117 Long-Term Sequelae,’’ revised in March either upper or lower extremities. is only for evaluating Raynaud’s 2002. https://www.publichealth.va.gov/ Buerger’s disease is a nonatherosclerotic syndrome (secondary Raynaud’s docs/vhi/coldinjury.pdf segmental inflammatory disease that phenomenon), and add a note This study collected medical and affects the small and medium-sized emphasizing that Raynaud’s disease anecdotal information on cold injury

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residuals from veterans. The study implantation or re-implantation. (clubbing, deformities).) VA proposes indicated that the effects of cold Following the initial month, the the addition of a note to provide weather injuries may be irreversible and disability will be evaluated using the examples of trophic changes for worsen with age. Id. at 15. The residuals General Rating Formula. To assist rating clarification purposes, consistent with of cold injuries include residual pain, personnel in understanding and other proposed changes. numbness, cold sensitivity, tissue loss, evaluating bradycardia, VA also VA also proposes to include a note to nail abnormalities, color changes, proposes to include a note under DC clarify and assist assigning evaluations locally impaired sensation, 7009 which defines bradycardia and under this DC by defining a hyperhidrosis, x-ray abnormalities, describes the five general classes of characteristic attack of Raynaud’s anhydrosis, muscle atrophy, muscle bradyarrhythmias. disease. As with DC 7117, this note will also indicate that evaluations under this fibrosis, deformity in flexion and/or B. New Diagnostic Code 7124 extension of certain joints, loss of fat code are for the disease as a whole. To pads in the fingers and toes, bone death, VA proposes to add a new DC 7124, further promote clarity and consistency, skin ulcers, and carpal or tarsal tunnel titled ‘‘Raynaud’s disease (also known another proposed note would syndrome. Id. at 24–25. VA proposes to as primary Raynaud’s phenomenon or emphasize that the purpose of DC 7124 include these updated residuals of cold primary Raynaud’s):.’’ The VASRD is to evaluate only Raynaud’s disease, as injuries within this DC, which assigns currently evaluates Raynaud’s disease opposed to Raynaud’s syndrome. A evaluations based on the number of cold using the criteria under DC 7117, which veteran cannot receive simultaneous injury residuals present. is for ‘‘Raynaud’s syndrome,’’ a different ratings under both DC 7117 and DC and more severe disability. Therefore, 7124, because Raynaud’s disease and IV. Proposed New Diagnostic Codes VA proposes a new DC to specifically Raynaud’s syndrome cannot be A. New Diagnostic Code 7009 evaluate Raynaud’s disease. This DC comorbid conditions. will also include notes to define VA proposes to add a new DC 7009, characteristic attacks as well as to Effect of Rulemaking titled ‘‘Bradycardia (Bradyarrhythmia), emphasize rating Raynaud’s syndrome Title 38 of the Code of Federal symptomatic, requiring permanent (Raynaud’s phenomenon, Secondary Regulations, as revised by this proposed pacemaker implantation,’’ to account for Raynaud’s) under DC 7117. rulemaking, would represent VA’s impairment in the Veteran population As stated previously, Raynaud’s implementation of its legal authority on due to this condition. Individuals disease is more common and tends to be this subject. Other than future generally have a normal resting heart less severe than Raynaud’s syndrome. amendments to these regulations or rate ranging from 60 to 100 beats per The Mayo Clinic performed a study governing statutes, no contrary guidance minute. Individuals with bradycardia, involving 474 women and girls with or procedures are authorized. All however, have a resting heart rate of less Raynaud’s disease. Follow-up existing or subsequent VA guidance than 60 beats per minute. information obtained from 307 of those must be read to conform with this ‘‘Bradycardia,’’ Harvard Health Topic at who received conservative treatment proposed rulemaking if possible or, if Drugs.com, http://www.drugs.com/ confirmed the benign nature of the not possible, such guidance is health-guide/bradycardia.html (last disease, with no deaths attributed to it superseded by this rulemaking. visited May 5, 2014). Notably, and extremely little disability. The Executive Orders 12866 and 13563 asymptomatic bradycardia occurs study found that uncomplicated normally in individuals when sleeping Raynaud’s disease may be inconvenient Executive Orders 12866 and 13563 and in many healthy, athletic adults. Id. because of the need to protect the direct agencies to assess the costs and See also ‘‘Bradycardia (Slow Heart extremities from cold and trauma, but it benefits of available regulatory Rate)—Topic Overview,’’ WebMD (Nov. is not disabling. alternatives and, when regulation is 21, 2011), http://www.webmd.com/ Raynaud’s disease, the less severe necessary, to select regulatory heart-disease/tc/bradycardia-slow- form of Raynaud’s, rarely involves approaches that maximize net benefits heart-rate-overview (last visited May 5, trophic changes because it involves brief (including potential economic, 2014). It should be noted that spasms of the arteries rather than environmental, public health and safety asymptomatic bradycardia is a medical occlusion of the peripheral arteries. See effects, and other advantages; finding, does not require medical ‘‘What is Raynaud’s?’’ National Heart, distributive impacts; and equity). intervention, and is not subject to Lung, and Blood Institute (Mar. 21, Executive Order 13563 (Improving service-connected compensation. 2014), https://www.nhlbi.nih.gov/ Regulation and Regulatory Review) Symptomatic bradycardia can be health/health-topics/topics/raynaud/ emphasizes the importance of caused by changes due to aging, certain (last visited May 5, 2014). Furthermore, quantifying both costs and benefits, medications, diseases, and infections, when trophic changes are present, they reducing costs, harmonizing rules, and all of which can damage the heart and are limited to the distal skin of the promoting flexibility. Executive Order slow its electrical impulses. See Amy digits. ‘‘Raynaud’s disease,’’ Mayo 12866 (Regulatory Planning and Scholten, MPH, ‘‘Bradycardia Clinic (Oct. 20, 2011), http:// Review) defines a ‘‘significant (Bradyarrhythmia),’’ NYU Langone www.mayoclinic.org/diseases- regulatory action,’’ which requires Cardiac and Vascular Institute, 2–3 (Feb. conditions/raynauds-disease/basics/ review by the Office of Management and 2008). When medical management for complications/con-20022916 (last Budget (OMB), as ‘‘any regulatory action symptomatic bradycardia is not visited May 5, 2014). Therefore, VA that is likely to result in a rule that may: effective, a pacemaker implant is the proposes a non-compensable evaluation (1) Have an annual effect on the treatment of choice. Id. at 3. when Raynaud’s disease manifests economy of $100 million or more or Implantation of a pacemaker aids in without lasting impairment in the form adversely affect in a material way the normalizing the heart rate and returning of trophic changes. VA proposes a 10 economy, a sector of the economy, the individual to baseline cardiac percent evaluation with residual trophic productivity, competition, jobs, the function. VA proposes to evaluate this changes (e.g., skin changes such as environment, public health or safety, or condition at 100 percent for one month thinning, atrophy fissuring, ulceration, State, local, or tribal governments or following hospitalization for scarring, absence of hair; nail changes communities; (2) Create a serious

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inconsistency or otherwise interfere Unfunded Mandates § 4.100 Application of the evaluation with an action taken or planned by criteria for diagnostic codes 7000–7007, another agency; (3) Materially alter the The Unfunded Mandates Reform Act 7011, and 7015–7020. budgetary impact of entitlements, of 1995 requires, at 2 U.S.C. 1532, that * * * * * grants, user fees, or loan programs or the agencies prepare an assessment of (b) Even if the requirement for a 10% rights and obligations of recipients anticipated costs and benefits before (based on the need for continuous thereof; or (4) Raise novel legal or policy issuing any rule that may result in the medication) or 30% (based on the issues arising out of legal mandates, the expenditure by State, local, and tribal presence of cardiac hypertrophy or President’s priorities, or the principles governments, in the aggregate, or by the dilatation) evaluation is met, METs set forth in this Executive Order.’’ private sector, of $100 million or more testing is required in all cases except: The economic, interagency, (adjusted annually for inflation) in any (1) When there is a medical budgetary, legal, and policy 1 year. This rule will have no such contraindication. implications of this regulatory action effect on State, local, and tribal (2) When a 100% evaluation can be have been examined and it has been governments, or on the private sector. assigned on another basis. determined to be a significant regulatory Catalog of Federal Domestic Assistance action under Executive Order 12866, (Authority: 38 U.S.C. 1155) because it raises novel legal or policy The Catalog of Federal Domestic ■ 3. Amend § 4.104 by: issues arising out of legal mandates, the Assistance program numbers and titles ■ a. Adding the General Rating Formula President’s priorities, or the principles for this rule are 64.104, Pension for for Diseases of the Heart set forth in this Executive Order. VA’s Non-Service-Connected Disability for ■ b. Adding the instruction to DCs 7000, impact analysis can be found as a Veterans; 64.109, Veterans 7001, 7002, 7006, 7017 to evaluate supporting document at http:// Compensation for Service-Connected disability using the General Rating www.regulations.gov, usually within 48 Disability; and 64.110, Veterans Formula to evaluate residual disability hours after the rulemaking document is Dependency and Indemnity after three months published. Additionally, a copy of the Compensation for Service-Connected ■ c. Adding the instruction to DCs 7003, rulemaking and its impact analysis are Death. 7004, 7005, 7007, and 7020 to evaluate available on VA’s website at http:// List of Subjects in 38 CFR Part 4 disability using the General Rating www.va.gov/orpm by following the link Formula for VA Regulations Published from FY Disability benefits, Pensions, ■ d. Adding the instruction to DCs 7011, 2004 through Fiscal Year to Date. This Veterans. 7016 to evaluate disability using the proposed rule is not expected to be Signing Authority General Rating Formula by mandatory subject to the requirements of EO13771 examination six months after discharge because this proposed rule is expected The Secretary of Veterans Affairs, or ■ e. Revising the evaluation criteria for to result in no more than de minimis designee, approved this document and DC 7015 costs. authorized the undersigned to submit it ■ f. Revising the evaluation criteria for Paperwork Reduction Act to the Office of the Federal Register for DC 7019 electronic publication as an official ■ g. Retitling and revise the evaluation This regulatory action contains document of the Department of Veterans provisions constituting a collection of criteria for DC 7010 Affairs. Robert L. Wilkie, Secretary, ■ h. Revising the evaluation criteria for information under the provisions of the Department of Veterans Affairs, Paperwork Reduction Act (44 U.S.C. DC 7018 approved this document on April 10, 3501 et seq.). ■ i. Retitling and revise the evaluation 2019, for publication. The information collection criteria for DC 7110 requirements for 38 CFR 3.151 are Dated: July 23, 2019. ■ j. Revising the evaluation criteria for associated with this rule, but do not Jeffrey M. Martin, DC 7111 constitute a new or revised collection of Assistant Director, Office of Regulation Policy ■ k. Revising DC 7113 to add information; OMB has already approved & Management, Office of the Secretary, explanatory information these requirements under control Department of Veterans Affairs. ■ l. Revising the evaluation criteria for number 2900–0747. For the reasons set out in the DC 7114 ■ Regulatory Flexibility Act preamble, VA proposes to amend 38 m. Revising the evaluation criteria for CFR part 4 as set forth below: DC 7115 The Secretary hereby certifies that the ■ n. Revising the evaluation criteria for adoption of this rule would not have a PART 4—SCHEDULE FOR RATING DC 7117 significant economic impact on a DISABILITIES ■ o. Revising the evaluation criteria for substantial number of small entities as DC 7120 they are defined in the Regulatory Subpart B—Disability Ratings ■ p. Revising the evaluation criteria for Flexibility Act, 5 U.S.C. 601–612. This DC 7122 rule would not directly affect any small ■ 1. The authority citation for part 4 ■ q. Adding new DC 7009 entities; only individuals could be continues to read as follows: ■ r. Adding new DC 7124. directly affected. Therefore, pursuant to The revisions and additions read as 5 U.S.C. 605(b), this rule is exempt from Authority: 38 U.S.C. 1155, unless otherwise noted. follows: the initial and final regulatory flexibility analysis requirements of sections 603 ■ 2. Revise § 4.100 paragraph (b) to read § 4.104 Schedule of ratings— and 604. as follows: cardiovascular system.

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Diseases of the Heart

Unless otherwise directed, use this general rating formula to evaluate diseases of the heart. Note (1): Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it. Note (2): One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which breathlessness, fatigue, angina, dizzi- ness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner may estimate the level of activity (expressed in METs and supported by spe- cific examples, such as slow stair climbing or shoveling snow) that results in those symptoms. Note (3): For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizzi- ness, arrhythmia, palpitations, or syncope. General Rating Formula for Diseases of the Heart: Workload of 3.0 METs or less results in heart failure symptoms ...... 100 Workload of 3.1–5.0 METs results in heart failure symptoms ...... 60 Workload of 5.1–7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging) ...... 30 Workload of 7.1–10.0 METs results in heart failure symptoms; or continuous medication required for control ...... 10 7000 Valvular heart disease (including rheumatic heart disease), 7001 Endocarditis, or 7002 Pericarditis: During active infection with cardiac involvement and for three months following cessation of therapy for the active infection 100 Thereafter, with diagnosis confirmed by findings on physical examination and either echocardiogram, Doppler echocardio- gram, or cardiac catheterization, use the General Rating Formula. 7003 Pericardial adhesions. 7004 Syphilitic heart disease: Note: Evaluate syphilitic aortic aneurysms under DC 7110 (Aortic aneurysm: Ascending, thoracic, abdominal). 7005 Arteriosclerotic heart disease (coronary artery disease). Note: If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non- arteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symp- toms. 7006 Myocardial infarction: During and for three months following myocardial infarction, confirmed by laboratory tests ...... 100 Thereafter, use the General Rating Formula. 7007 Hypertensive heart disease. 7008 Hyperthyroid heart disease: Rate under the appropriate cardiovascular diagnostic code, depending on particular findings. For DCs 7009, 7010, 7011, and 7015, a single evaluation will be assigned under the diagnostic code which reflects the pre- dominant disability picture. 7009 Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation: For one month following hospital discharge for implantation or re-implantation ...... 100 Thereafter, use the General Rating Formula. Note (1): Bradycardia (bradyarrhythmia) refers to conduction abnormalities that produce a heart rate less than 60 beats/ min. There are five general classes of bradyarrhythmias: —Sinus bradycardia, including sinoatrial block; —Atrioventricular (AV) junctional (nodal) escape rhythm; —AV heart block (second or third degree) or AV dissociation; —Atrial fibrillation or flutter with a slow ventricular response; and —Idioventricular escape rhythm. Note (2): Asymptomatic bradycardia (bradyarrhythmia) is a medical finding which does not require medical intervention, thus, it is not entitled to service connection. 7010 Supraventricular tachycardia: Confirmed by ECG, with five or more treatment interventions per year ...... 30 Confirmed by ECG, with one to four treatment interventions per year ...... 10 Note (1): Examples of supraventricular tachycardia include, but are not limited to, atrial fibrillation, atrial flutter, sinus tachy- cardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachy- cardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Note (2): For the purposes of this diagnostic code, a treatment intervention occurs whenever a symptomatic patient re- quires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. 7011 Ventricular arrhythmias (sustained): For an indefinite period from the date of hospital admission for initial medical therapy for a sustained ventricular arrhythmia; or for an indefinite period from the date of hospital admission for ventricular aneurysmectomy; or with an automatic implantable cardioverter-defibrillator (AICD) in place ...... 100 Thereafter, use the General Rating Formula. Note: Six months following discharge from inpatient hospitalization for sustained ventricular arrhythmia or for ventricular aneurysmectomy, disability evaluation shall be conducted by mandatory VA examination using the General Rating For- mula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7015 Atrioventricular block: Benign (First-Degree and Second-Degree, Type I): Evaluate under the General Rating Formula. Non-Benign (Second-Degree, Type II and Third-Degree): Evaluate under DC 7018 (implantable cardiac pacemakers). 7016 Heart valve replacement (prosthesis): For an indefinite period following date of hospital admission for valve replacement ...... 100 Thereafter, use the General Rating Formula.

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Rating

Note: Six months following discharge from inpatient hospitalization, disability evaluation shall be conducted by mandatory VA examination using the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7017 Coronary bypass surgery:. For three months following hospital admission for surgery ...... 100 Thereafter, use the General Rating Formula. 7018 Implantable cardiac pacemakers: For one month following hospital discharge for implantation or re-implantation ...... 100 Thereafter: Evaluate as supraventricular tachycardia (DC 7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC 7015). Minimum ...... 10 Note (1): Evaluate automatic implantable cardioverter-defibrillators (AICDs) under DC 7011. 7019 Cardiac transplantation: For a minimum of one year from the date of hospital admission for cardiac transplantation ...... 100 Thereafter: Evaluate under the General Rating Formula. Minimum ...... 30 Note: One year following discharge from inpatient hospitalization, determine the appropriate disability rating by mandatory VA examination. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7020 Cardiomyopathy.

Diseases of the Arteries and Veins

7110 Aortic aneurysm: Ascending, thoracic, or abdominal: If 5 centimeters (cm) or larger in diameter; or, if symptomatic (e.g., precludes exertion) and a physician recommends sur- gical correction, for the period beginning on the date a physician recommends surgical correction and continuing for six months following hospital discharge for surgical correction (including any type of graft insertion) ...... 100 If less than 5 cm in diameter; or, surgical correction not recommended ...... 0 Evaluate non-cardiovascular residuals of surgical correction according to organ systems affected. Note: Six months following discharge from inpatient hospitalization for surgery, disability evaluation shall be determined by mandatory VA examination of cardiovascular residuals using the General Rating Formula for Diseases of the Heart. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. 7111 Aneurysm, any large artery: If symptomatic; or, for the period beginning on the date a physician recommends surgical correction and continuing for six months following discharge from inpatient hospital admission for surgical correction ...... 100 Following surgery: Evaluate under DC 7114 (peripheral arterial disease). Note: Six months following discharge from inpatient hospitalization for surgery, determine the appropriate disability rating 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. . ******* 7113 Arteriovenous fistula, traumatic: With high-output heart failure ...... 100 Without heart failure but with enlarged heart, wide pulse pressure, and tachycardia ...... 60 Without cardiac involvement but with chronic edema, stasis dermatitis, and either ulceration or cellulitis: Lower extremity ...... 50 Upper extremity ...... 40 Without cardiac involvement but with chronic edema or stasis dermatitis: Lower extremity ...... 30 Upper extremity ...... 20 7114 Peripheral arterial disease: At least one of the following: Ankle/brachial index less than or equal to 0.39; ankle pressure less than 50 mm Hg; toe pres- sure less than 30 mm Hg; or transcutaneous oxygen tension less than 30 mm Hg ...... 100 At least one of the following: Ankle/brachial index of 0.40–0.53; ankle pressure of 50–65 mm Hg; toe pressure of 30–39 mm Hg; or transcutaneous oxygen tension of 30–39 mm Hg ...... 60 At least one of the following: Ankle/brachial index of 0.54–0.66; ankle pressure of 66–83 mm Hg; toe pressure of 40–49 mm Hg; or transcutaneous oxygen tension of 40–49 mm Hg ...... 40 At least one of the following: Ankle/brachial index of 0.67–0.79; ankle pressure of 84–99 mm Hg; toe pressure of 50–59 mm Hg; or transcutaneous oxygen tension of 50–59 mm Hg ...... 20 Note (1): The ankle/brachial index (ABI) is the ratio of the systolic blood pressure at the ankle divided by the simultaneous brachial artery systolic blood pressure. For the purposes of this diagnostic code, normal ABI will be greater than or equal to 0.80. The ankle pressure (AP) is the systolic blood pressure measured at the ankle. Normal AP is greater than or equal to 100 mm Hg. The toe pressure (TP) is the systolic blood pressure measured at the great toe. Normal TP is greater than or equal to 60 mm Hg. Transcutaneous oxygen tension (TcPO2) is measured at the first intercostal space on the foot. Normal TcPO2 is greater than or equal to 60 mm Hg. All measurements must be determined by objective test- ing. Note (2): Select the highest impairment value of ABI, AP, TP, or TcPO2 for evaluation. Note (3): Evaluate residuals of aortic and large arterial bypass surgery or arterial graft as peripheral arterial disease. Note (4): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity sep- arately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. 7115 Thrombo-angiitis obliterans (Buerger’s Disease):

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Lower extremity: Rate under DC 7114. Upper extremity: Deep ischemic ulcers and necrosis of the fingers with persistent coldness of the extremity, trophic changes with pains in the hand during physical activity, and diminished upper extremity pulses ...... 100 Persistent coldness of the extremity, trophic changes with pains in the hands during physical activity, and diminished upper extremity pulses ...... 60 Trophic changes with numbness and paresthesia at the tips of the fingers, and diminished upper extremity pulses ...... 40 Diminished upper extremity pulses ...... 20 Note (1): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity sep- arately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, ab- sence of hair) as well as nail changes (clubbing, deformities). 7117 Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon or secondary Raynaud’s). With two or more digital ulcers plus auto-amputation of one or more digits and history of characteristic attacks ...... 100 With two or more digital ulcers and history of characteristic attacks ...... 60 Characteristic attacks occurring at least daily ...... 40 Characteristic attacks occurring four to six times a week ...... 20 Characteristic attacks occurring one to three times a week ...... 10 Note (1): For purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for Raynaud’s syndrome as a whole, regardless of the number of extremities in- volved or whether the nose and ears are involved. Note (2): This section is for evaluating Raynaud’s syndrome (secondary Raynaud’s phenomenon or secondary Raynaud’s). For evaluation of Raynaud’s disease (primary Raynaud’s phenomenon, or primary Raynaud’s), see DC 7124. . ******* 7120 Varicose veins: Evaluate under diagnostic code 7121. . ******* 7122 Cold injury residuals: With the following in affected parts: Arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome ...... 30 Arthralgia or other pain, numbness, or cold sensitivity plus one of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome ...... 20 Arthralgia or other pain, numbness, or cold sensitivity ...... 10 Note (1): Separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, under other diagnostic codes. Separately evaluate other disabilities di- agnosed as the residual effects of cold injury, such as Raynaud’s syndrome (which is otherwise known as secondary Raynaud’s phenomenon), muscle atrophy, etc., unless they are used to support an evaluation under diagnostic code 7122. Note (2): Evaluate each affected part (e.g., hand, foot, ear, nose) separately and combine the ratings in accordance with §§ 4.25 and 4.26. . ******* 7124 Raynaud’s disease (also known as primary Raynaud’s phenomenon or primary Raynaud’s):. Characteristic attacks associated with trophic change(s), such as tight, shiny skin ...... 10 Characteristic attacks without trophic change(s) ...... 0 Note (1): For purposes of this section, characteristic attacks consist of intermittent and episodic color changes of the digits of one or more extremities, lasting minutes or longer, with occasional pain and paresthesias, and precipitated by expo- sure to cold or by emotional upsets. These evaluations are for the disease as a whole, regardless of the number of ex- tremities involved or whether the nose and ears are involved. Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, ab- sence of hair) as well as nail changes (clubbing, deformities). Note (3): This section is for evaluating Raynaud’s disease (primary Raynaud’s phenomenon or primary Raynaud’s). For evaluation of Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon, or secondary Raynaud’s), see DC 7117.

(Authority: 38 U.S.C. 1155) ■ b. Revising the entries for diagnostic 7110 through 7111, 7113 through 7115, codes 7000 through 7008; 7117, and 7121 through 7122; and ■ 4. Amend Appendix A to Part 4 by: ■ c. Adding, in numerical order, an ■ e. Adding, in numerical order, an ■ a. Adding an entry for the General entry for diagnostic code 7009; entry for diagnostic code 7124. Rating Formula for Diseases of the Heart ■ d. Revising the entries for diagnostic The revisions and additions read as to 4.104; codes 7010, 7011, 7015 through 7020, follows:

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APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946

Diagnostic Sec. code No.

******* 4.104 ...... General Rating Formula for Diseases of the Heart [Effective date of final rule]. 7000 Evaluation July 6, 1950; evaluation September 22, 1928, evaluation January 12, 1998; criterion [Effective date of final rule]. 7001 Evaluation January 12, 1998; criterion [Effective date of final rule]. 7002 Evaluation January 12, 1998; criterion [Effective date of final rule]. 7003 Evaluation January 12, 1998; criterion [Effective date of final rule]. 7004 Criterion September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. 7005 Evaluation September 9, 1975; evaluation September 22, 1978; evaluation January 12, 1998; criterion [Effec- tive date of final rule]. 7006 Evaluation January 12, 1998; criterion [Effective date of final rule] 7007 Evaluation September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. 7008 Evaluation January 12, 1998; evaluation [Effective date of final rule]. 7009 Added [Effective date of final rule]. 7010 Evaluation January 12, 1998; title, criterion [Effective date of final rule]. 7011 Evaluation January 12, 1998; note, criterion [Effective date of final rule].

******* 7015 Evaluation September 9, 1975; criterion January 12, 1998; criterion [Effective date of final rule]. 7016 Added September 9, 1975; criterion January 12, 1998; note, criterion [Effective date of final rule]. 7017 Added September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. 7018 Added January 12, 1998; criterion [Effective date of final rule]. 7019 Added January 12, 1998; note, criterion [Effective date of final rule]. 7020 Added January 12, 1998; criterion [Effective date of final rule].

******* 7110 Evaluation September 9, 1975; evaluation January 12, 1998; title, criterion, note [Effective date of final rule]. 7111 Criterion September 9, 1975; evaluation January 12, 1998; note, criterion [Effective date of final rule].

******* 7113 Evaluation January 12, 1998; criterion [Effective date of final rule]. 7114 Added June 9, 1952; evaluation January 12, 1998; title, criterion, note [Effective date of final rule]. 7115 Added June 9, 1952; evaluation January 12, 1998; note, criterion, evaluation [Effective date of final rule].

******* 7117 Added June 9, 1952; evaluation January 12, 1998; title, note [Effective date of final rule].

******* 7121 Criterion July 6, 1950; evaluation March 10, 1976; evaluation January 12, 1998; criterion [Effective date of final rule]. 7122 Last sentence of Note following July 6, 1950; evaluation January 12, 1998; criterion August 13, 1998; criterion [Effective date of final rule].

******* 7124 Added [Effective date of final rule].

*******

■ 5. Amend Appendix B to Part 4, ■ b. Revising diagnostic codes 7010, The revisions and additions read as § 4.104 by: 7110, 7114, and 7117; and follows: ■ a. Adding, in numerical order, an ■ c. Adding, in numerical order, an entry for diagnostic code 7009; entry for diagnostic code 7124.

APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES

Diagnostic code No.

*******

The Cardiovascular System—Diseases of the Heart

******* 7009 ...... Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation.

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APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES—Continued

Diagnostic code No.

******* 7010 ...... Supraventricular tachycardia.

******* 7110 ...... Aortic aneurysm: ascending, thoracic, abdominal.

******* 7114 ...... Peripheral arterial disease.

******* 7117 ...... Raynaud’s syndrome (secondary Raynaud’s phenomenon).

******* 7124 ...... Raynaud’s disease (primary Raynaud’s phenomenon, primary Raynaud’s).

*******

■ 6. Revise Appendix C to Part 4, ■ c. Revising the entries for (primary Raynaud’s phenomenon, § 4.104 by: Hypertension (isolated systolic, primary Raynaud’s); and ■ a. Revising the entry for Aneurysm: diastolic, or combined systolic and ■ e. Revising the entries for Raynaud’s Aortic: ascending, thoracic, abdominal; diastolic hypertension) and Peripheral syndrome (Raynaud’s phenomenon, ■ b. Adding, in alphabetical order, arterial disease; under the entry for Bones an entry for secondary Raynaud’s) and ■ Bradycardia (Bradyarrhthmia), d. Adding, in alphabetical order, Supraventricular tachycardia. symptomatic, requiring permanent under the entry for Pyelonephritis, The revisions and additions read as pacemaker implantation; chronic, an entry for Raynaud’s disease follows:

APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES

Diagnostic code No.

******* Aneurysm: Aortic: ascending, thoracic, abdominal ...... 7110 Large artery ...... 7111 Small artery ...... 7118

******* Arrhythmia: Ventricular ...... 7011

******* Bones: Bradycardia ...... 7009 (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation.

******* Peripheral arterial disease ...... 7114

******* Raynaud’s disease (primary Raynaud’s) ...... 7124 Raynaud’s syndrome (Raynaud’s phenomenon, secondary Raynaud’s) ...... 7117

******* Supraventricular tachycardia ...... 7010

*******

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[FR Doc. 2019–15904 Filed 7–31–19; 8:45 am] full EPA public comment policy, in any areas located within ozone BILLING CODE 8320–01–P information about CBI or multimedia transport regions established pursuant submissions, and general guidance on to section 184. This requirement is making effective comments, please visit referred to as OTR RACT. A single ENVIRONMENTAL PROTECTION http://www2.epa.gov/dockets/ ozone transport region (the OTR) has AGENCY commenting-epa-dockets. been established under section 184(a), FOR FURTHER INFORMATION CONTACT: which comprises of 12 States, including 40 CFR Part 52 Emlyn Ve´lez-Rosa, Planning & the District of Columbia, the Northern portion of Virginia, and portions of [EPA–R03–OAR–2019–0277; FRL–9997–70– Implementation Branch (3AD30), Air & Region 3 ] Radiation Division, U.S. Environmental Maryland as part of the Consolidated Protection Agency, Region III, 1650 Metropolitan Statistical Area (CMSA). Approval and Promulgation of Air Arch Street, Philadelphia, Pennsylvania The Northern portion of Virginia Quality Implementation Plans; Virginia; 19103. The telephone number is (215) (hereafter Northern Virginia) consists of Source-Specific Reasonably Available 814–2038. Ms. Ve´lez-Rosa can also be the Arlington County, Fairfax County, Control Technology Determinations for reached via electronic mail at velez- Loudoun County, Prince William 2008 Ozone National Ambient Air [email protected]. County, Alexandria City, Fairfax City, Falls Church City, Manassas City, Quality Standard SUPPLEMENTARY INFORMATION: On Manassas Park City, and Strafford AGENCY: Environmental Protection February 1, 14, and 15, 2019, the County. The three facilities which are Agency (EPA). Virginia Department of Environmental the subject of this Notice of Proposed Quality (VADEQ) submitted three ACTION: Proposed rule. Rulemaking are located in Northern separate revisions to its SIP addressing Virginia, and thus subject to OTR RACT. SUMMARY: The Environmental Protection RACT under the 2008 ozone NAAQS for On March 12, 2008, EPA revised the Agency (EPA) is proposing to approve three facilities in Northern Virginia. The 8-hour ozone standards, by lowering the three state implementation plan (SIP) SIP revisions consist of source-specific standard to 0.075 parts per million revisions submitted by the RACT determinations for each facility. (ppm) averaged over an 8-hour period Commonwealth of Virginia. These I. Background (2008 ozone NAAQS). See 73 FR 16436. revisions address reasonably available On May 21, 2012, EPA designated the control technology (RACT) requirements RACT is an important strategy for Washington, DC-MD-VA area as a under the 2008 ozone national ambient reducing oxides of nitrogen (NOX) and marginal ozone nonattainment area for air quality standard (NAAQS) for three volatile organic compounds (VOC) the 2008 ozone NAAQS. The facilities in Northern Virginia through emissions from major stationary sources Washington, DC-MD-VA marginal ozone source-specific determinations. This within areas not meeting the ozone nonattainment area includes all cities action is being taken under the Clean NAAQS. Since the 1970’s, EPA has and counties in the Northern portion of Air Act (CAA). consistently defined ‘‘RACT’’ as the Virginia that are part of the OTR, with lowest emission limit that a particular DATES: Written comments must be exception of the Strafford County. See source is capable of meeting by the received on or before September 3, 77 FR 30088 and 40 CFR 81.347. application of the control technology 2019. On March 6, 2015, EPA issued its that is reasonably available considering final rule for implementing the 2008 ADDRESSES: Submit your comments, technological and economic feasibility.1 ozone NAAQS (‘‘the 2008 Ozone SIP identified by Docket ID No. EPA–R03– Section 172(c)(1) of the CAA provides Requirements Rule’’).2 In addressing OAR–2019–0277 at https:// that SIPs for nonattainment areas must RACT requirements, the 2008 Ozone SIP www.regulations.gov, or via email to include reasonably available control Requirements Rule is consistent with [email protected]. For measures (RACM) for demonstrating existing policy and EPA’s previous comments submitted at Regulations.gov, attainment of all NAAQS, including ozone implementation rule. For 2008 follow the online instructions for emissions reductions from existing ozone NAAQS, only Northern Virginia submitting comments. Once submitted, sources through adoption of RACT. In is subject to RACT due to its location in comments cannot be edited or removed addition, Section 182 of the CAA sets the OTR, as no moderate nonattainment from Regulations.gov. For either manner forth additional RACT requirements for areas were designated by EPA under the of submission, EPA may publish any the ozone NAAQS for moderate, serious standard. comment received to its public docket. or severe nonattainment areas. Section Do not submit electronically any 182 requires states to implement RACT II. Summary of SIP Revision and EPA information you consider to be for VOC sources in the area covered by Analysis confidential business information (CBI) a control technique guideline (CTG) Virginia’s February 1, 14, and 15, or other information whose disclosure is document issued by EPA, all other 2019 SIP revisions address NOX and/or restricted by statute. Multimedia major stationary sources of VOCs that VOC RACT for the following facilities: submissions (audio, video, etc.) must be are located in the area, and major Virginia Electric and Power Company— accompanied by a written comment. stationary sources of NOX. The section Possum Point Power Station, Covanta The written comment is considered the 182 RACT requirements are usually Alexandria/Arlington, Inc., and Covanta official comment and should include referred to as CTG RACT, major non- Fairfax, Inc. VADEQ is adopting as part discussion of all points you wish to CTG VOC RACT, and major NOX RACT. of these SIP revisions additional NOX make. EPA will generally not consider Further, section 184(b)(1)(B) of the control requirements for these three comments or comment contents located CAA requires states to implement RACT facilities to meet RACT under the 2008 outside of the primary submission (i.e. ozone NAAQS, all of which are on the web, cloud, or other file sharing 1 See December 9, 1976 memorandum from Roger implemented via Federally enforceable system). For additional submission Strelow, Assistant Administrator for Air and Waste permits issued by VADEQ. These RACT Management, to Regional Administrators, methods, please contact the person ‘‘Guidance for Determining Acceptability of SIP permits, as listed on Table 1, have been identified in the FOR FURTHER Regulations in Non-Attainment Areas,’’ and also 44 INFORMATION CONTACT section. For the FR 53762; September 17, 1979. 2 80 FR 12264 (March 6, 2015).

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