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M21-1, Part III, Subpart iv, Chapter 4, Section F – Respiratory Conditions

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4
5
6
7

 1.  Basic Rating Principles for Respiratory Conditions


Introduction

This topic contains basic rating principles for respiratory conditions, including

Change Date

April 18, 2018

III.iv.4.F.1.a.  Prohibition of Evaluations for Certain Coexisting Respiratory Disabilities

38 CFR 4.96(a) prohibits the assignment of separate evaluations for co-existing respiratory conditions rated under 38 CFR 4.97, diagnostic codes (DCs) 6600 through 6817 and 6822 through 6847.
38 CFR 4.97, DCs 6819 and 6820 (malignant and benign neoplasms) are rated on residuals, including any residual disability of the respiratory system.  Therefore, where there is lung or pleural involvement, separate evaluations under 38 CFR 4.97, DCs 6819 and 6820 are prohibited.  If an evaluation has already been assigned under either 38 CFR 4.97, DCs 6819 or 6820, separate evaluations are also prohibited under 38 CFR 4.97, DCs 6600 through 6817 and 6822 through 6847.
Reference:  For more information on pyramiding, see

III.iv.4.F.1.b.  Evaluating Coexisting Respiratory Disabilities

Under 38 CFR 4.96(a) when there are coexisting respiratory disabilities for which multiple evaluations cannot be assigned
  • a single rating will be assigned under the DC which reflects the predominant disability, and
  • that evaluation will be elevated to the next higher evaluation, when the severity of the overall disability warrants it.
Exception:  In cases protected by the provisions of Public Law 90-493, the graduated ratings of 50 and 30 percent for inactive tuberculosis will not be elevated.
The Veterans Benefits Management System – Rating Evaluation Builder is programmed to appropriately apply the provisions of 38 CFR 4.96(a) but it is critical that
  • the user input the symptoms that support the elevation, and
  • the symptoms coincide with the criteria listed in the rating schedule.
Refer to the table below for instructions on proper application of the 38 CFR 4.96(a) provision on assigning an evaluation in cases of multiple qualifying coexisting respiratory disabilities.
Step
Action
1
Determine which of the coexisting respiratory conditions is the predominant disability.
Important:
  • To determine the predominant disability, determine the evaluation each condition would warrant on its own.  The condition that has the highest disability evaluation is the predominant disability.
  • If the same evaluation would be assigned to each, go through the analysis in the steps, alternatively treating each condition as the predominant one to see if one alternative provides a more advantageous outcome to the Veteran.
2
Determine if there are symptoms of the non-predominant disability that do not overlap with those of the predominant disability.
  • If yes, go to Step 3.
  • If no, go to Step 4.
3
Reevaluate the predominant disability but this time also consider the non-overlapping symptoms of the non-predominant disability.
Important:  The non-overlapping symptoms must support a higher evaluation when applied to the DC criteria being utilized for the predominant disability.
Determine if the resultant evaluation is higher than the evaluation for the symptoms of the predominant disability alone (as derived in Step 1).
  • If yes, go to Step 5.
  • If no, go to Step 4.
4
  • Rate the coexistent disabilities together under the rating criteria for the predominant disability without elevation to the next higher evaluation.
  • No further action necessary.
5
  • Rate the coexistent disabilities together under the rating criteria for the predominant disability and elevate to the next higher evaluation.
  • No further action necessary.
Important:
  • The “next higher level of evaluation” is the lowest evaluation specified in the DC for the predominant disability that provides greater compensation than the evaluation derived in Step 1 (the evaluation that would be supported by only the symptoms of the predominant disability without the symptoms of the lesser disability).  Do not simply add 10 percent.
  • Although elevation remains a legal option under the existing regulatory language, because evaluations in the specified DCs overwhelmingly use mostly-overlapping and mostly-objective criteria, in many cases the result of the analysis specified in the table will be a conclusion that elevation is not appropriate.
References:  For

III.iv.4.F.1.c.  Example 1 – Evaluating Coexisting Respiratory Disabilities

Situation:  Sleep apnea (38 CFR 4.97, DC 6847) warrants an evaluation of 50 percent based on the need for a continuous positive airway pressure (CPAP) machine.  Chronic obstructive pulmonary disease (COPD) (38 CFR 4.97, DC 6604) is coexistent and warrants a 30-percent evaluation based on pulmonary function tests (PFTs).
Result:  The predominant condition is the sleep apnea as it justifies a higher evaluation.  There are no non-overlapping symptoms of COPD to establish any of the criteria for which the next higher (100 percent) evaluation could be assigned for sleep apnea:  chronic respiratory failure with carbon dioxide retention or cor pulmonale, or need for tracheostomy.  Therefore elevation is not appropriate.

III.iv.4.F.1.d.  Example 2 – Evaluating Coexisting Respiratory Disabilities

Situation:  Asbestosis (38 CFR 4.97, DC 6833) warrants an evaluation of 30 percent based on diffusion capacity of the lung for carbon monoxide (DLCO).  Asthma (38 CFR 4.97, DC 6602) is coexistent and warrants a 30-percent evaluation based on inhalational anti-inflammatory medication.
Result:  Neither is predominant as each would justify a 30-percent evaluation.   The use of medications is not considered in next higher criteria for 38 CFR 4.97, DC 6833 (Forced Vital Capacity (FVC) of 50 to 64 percent of predicted; DLCO of 40-55 percent of predicted; or, maximum exercise capacity of less than 15 ml/kg/min of oxygen consumption with cardiorespiratory limitation) and does not provide any basis for elevation. Conversely, the DLCO result for asbestosis is not considered in the next higher criteria for 38 CFR 4.97, DC 6602 (Forced Expiratory Volume in one second (FEV-1) of 40 to 55 percent predicted; FEV-1/FVC of 40 to 55 percent; at least monthly visits to a physician for required care of exacerbations; or, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids).  Therefore, elevation is not appropriate.

III.iv.4.F.1.e.Requirement for PFTs

PFT results are required for 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845 as specified at 38 CFR 4.96(d) except when
  • the results of a maximum exercise capacity test are of record and are 20 milliliters/per kilogram of body weight per minute (ml/kg/min) or less
  • pulmonary hypertension has been diagnosed
  • cor pulmonale has been diagnosed
  • right ventricular hypertrophy has been diagnosed
  • there have been one or more episodes of acute respiratory failure, or
  • outpatient oxygen therapy is required.
Notes:
  • If a maximum exercise capacity test is not of record, evaluate based on alternative criteria.
  • A diagnosis of pulmonary hypertension requires objective documentation by an echocardiogram or cardiac catheterization.
  • When the rating criteria for a disability not regulated by 38 CFR 4.96(d)include PFTs among the potential methods for assigning a disability evaluation, such as 38 CFR 4.97, DC 6602 for asthma, PFTs are not required to evaluate the disability.  However, if PFTs were previously utilized to assign a disability evaluation and consideration is being given to a reduced evaluation, apply 38 CFR 3.344(a).  When the prior evaluation was assigned based on PFTs, the current examination must also include PFTs if a reduced evaluation due to improvement is being considered.
Reference:  For more information on when PFTs are required, see 38 CFR 4.96(d).

III.iv.4.F.1.f.Assigning Disability Evaluations Based on the Results of PFTs

The table below contains instructions for assigning disability evaluations based on the results of PFTs.  This table applies to 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845 as specified at 38 CFR 4.96(d).
If …
And …
Then …
PFTs are not consistent with clinical findings
the examiner does notstate why PFTs are not a valid indication of respiratory disability
evaluate based on PFTs.
PFTs are not consistent with clinical findings
the examiner states why PFTs are not a valid indication of respiratory disability
evaluate based on alternative criteria.
there is a disparity between PFT results  (FEV-1, FVC, FEV-1/FVC, DLCO)
the evaluation would differ depending on the test result used
use the test result that the examiner states most accurately reflects the level of disability.
FEV-1 is greater than 100 percent
FVC is greater than 100 percent
do not assign a compensable evaluation based on a decreased FEV-1/FVC ratio.
DLCO is not of record
the examiner states why DLCO would not be useful or valid
evaluate based on alternative criteria.
DLCO is not of record
the examiner does notstate why DLCO would not be useful or valid
return the examination as insufficient and request clarification.

III.iv.4.F.1.g.Post-Bronchodilator Studies, Requirements, and Evaluations

Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes for disabilities rated under 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845 except when
  • the results of pre-bronchodilator PFTs are normal
  • the examiner determines that post-bronchodilator studies should not be done and states why, or
  • using the DLCO score values (Clinicians have stated that bronchodilator use has no effect on DLCO values.)
When evaluating based on PFTs, use post-bronchodilator results unless the post-bronchodilator results were poorer than the pre-bronchodilator results.  In those cases, use the pre-bronchodilator values for rating purposes.

III.iv.4.F.1.h.DLCO Testing

When utilizing DLCO to evaluate a respiratory disability, only test results recognized as DLCO or DLCO by the single breath method (DLCO (SB)) will be utilized for rating purposes.
DLCO divided by alveolar volume (DLCO/VA) is a variant of DLCO (SB) in which the DLCO is divided by the alveolar volume of the lungs. There is no provision for considering DLCO/VA under 38 CFR 4.96 or 38 CFR 4.97. Consequently, DLCO/VA cannot be utilized for rating purposes.

2.  General Information on Tuberculosis


Introduction

This topic contains general information about tuberculosis, including


Change Date

April 15, 2015

III.iv.4.F.2.a.  Tuberculosis Classification Standards

Become familiar with the following classification standards adopted by the American Lung Association under The Diagnostic Standards and Classification of Tuberculosis in Adults and Children1999:

  • Classify an individual as Tuberculosis Suspect until diagnostic procedures are complete.  (Note:  Do not use the classification Tuberculosis Suspectfor more than three months.)
  • Classify disease caused by other mycobacteria as Other Mycobacterial Diseases.  (Note:  Disease caused by other mycobacteria is indistinguishable clinically, radiologically, and histologically from mycobacterium (M.) tuberculosis.)

Reference:  For more information on the classification standards, see TheDiagnostic Standards and Classification of Tuberculosis in Adults and Children1999.


III.iv.4.F.2.b.  Considering Infection Caused by Other Mycobacteria

Other mycobacteria that may commonly be involved as pathogens are
  • M. kansasii
  • M. intracellulare, and
  • M. scrofulaceum.
Note:  M. bovis is
  • rarely responsible for disease where there is effective control of tuberculosis in cattle and pasteurization of milk and milk products, and
  • indistinguishable from M. tuberculosis except by culture.

III.iv.4.F.2.c.  Diagnosing Infection Caused by Other Mycobacteria

A definitive diagnosis for infection caused by other mycobacteria requires
  • evidence of disease (such as an infiltrate visible on a chest x-ray)
  • no other cause established by careful clinical and laboratory studies, and
  • either
    • appearance of the same strain of mycobacteria repeatedly, or
    • isolation of the mycobacteria from a closed lesion from which the specimen has been collected and handled under sterile conditions.
Note:  Diagnosis of other mycobacterial infection by skin test is not possible.  The current antigens for mycobacteria other than M. tuberculosis have high cross-reactivity and low specificity.

III.iv.4.F.2.d.  Classifying Disease Caused by Other Mycobacteria

With certain modifications, the classification for tuberculosis is adaptable for classifying other mycobacterial diseases.
When classifying mycobacterial diseases, do not use the following three categories used for tuberculosis
  • no exposure, not infected
  • exposure, no evidence of infection,” or
  • infection, without disease.”

III.iv.4.F.2.e.  Considering Chest X-Rays Under 38 CFR 3.370 and 38 CFR 3.371

If active pulmonary tuberculosis is claimed to be service-connected (SC) and entitlement is not established by other evidence, then consider the x-ray evidence in accordance with 38 CFR 3.370 and 38 CFR 3.371.
Reports of x-ray interpretations must be adequate for rating purposes.
Use the table below to determine which x-ray films are required to prove service connection (SC).
To prove …
Films required are …
direct SC
all service films.
presumptive SC
discharge film (or a service film used for this) and an adequate number of post-service films.

III.iv.4.F.2.f.  Referrals for X-Ray Interpretation Under 38 CFR 3.370 and 38 CFR 3.371

Only designees of the Under Secretary for Health are authorized to interpret x-ray films under 38 CFR 3.370 and 38 CFR 3.371.  Refer requests for interpretations to the Department of Veterans Affairs (VA) medical facility for the local regional office (RO).
Note:  If the local VA medical facility is not authorized to make such interpretations, the Director will keep the RO informed of the current location of the designated interpreter for the RO area.  In such a case, refer requests directly to the clinic, center, or hospital.

III.iv.4.F.2.g.  Processing Claims Based on Tuberculin Reaction

Reference:  For more information on claims based on positive tuberculin reaction, see M21-1, Part IV, Subpart ii, 1.I.1.

3.  Arrested Tuberculosis


Introduction

This topic contains information about arrested tuberculosis, including

Change Date

August 3, 2011

III.iv.4.F.3.a.  Processing Graduated Ratings in Effect on August 19, 1968

For graduated ratings in effect on August 19, 1968,
  • award a total evaluation for two years after the date of complete arrest or inactivity established under 38 CFR 3.375(a)
  • as set forth under the general rating formula following 38 CFR 4.97, DC 6724 of the rating schedule
    • reduce the evaluation to 50 percent for four years, and
    • reduce the evaluation to 30 percent for another five years, and
  • after the expiration of the 11-year period
    • continue the 30-percent evaluation, if far advanced active lesions exist
    • assign a 20-percent evaluation, if there are moderately advanced lesions with continued disability, or
    • assign a 0-percent evaluation if the first two criteria do not apply.

III.iv.4.F.3.b.  Processing Ratings in Effect After August 19, 1968

If pulmonary tuberculosis is established after August 19, 1968,
  • continue the 100-percent evaluation for one year after the date of inactivity established under 38 CFR 3.375(a), and
  • thereafter apply the general rating formula for residuals in the rating schedule under 38 CFR 4.97, DC 6731.

III.iv.4.F.3.c.  Requesting Examinations During the Graduated Rating Period

Do not request an examination for rating purposes during the period covered by the graduated ratings.

III.iv.4.F.3.d.  Processing Notification of Failure to Follow Treatment or Submit to Examination

Medical authorities will notify the RO of a Veteran’s failure to follow prescribed treatment or submit to examination requested for treatment purposes during the period of total disability following complete arrest of the tuberculosis.
After the notification is received, follow the due process procedures of 38 CFR 3.655 and furnish the Veteran a notice of proposed adverse action.  Upon expiration of the due process period
  • reduce the 100-percent evaluation to 50 percent by rating action, and
  • adjust the Veteran’s award as of the date of the last payment or the date indicated in the notice of proposed adverse action, whichever is later.
Notes:
  • The reduction of the 100-percent evaluation upon failure to submit to examination or follow prescribed treatment is applicable only when the tuberculosis has reached a stage of complete arrest or inactivity.
  • If the Veteran complies with the request for examination during the original two-year time frame for the 100-percent graduated rating, restore the 100-percent rating effective the date of reduction.

III.iv.4.F.3.e.  Processing Cases of Irregular Discharge

Do not suspend or discontinue payments merely because a Veteran with active tuberculosis receives an irregular discharge.  An irregular discharge is received for disciplinary reasons, the refusal to accept or follow treatment, the refusal to accept transfer, or failure to return from an authorized absence.
In the case of irregular discharge,
  • continue the 100-percent evaluation based on activity, and
  • request an examination six months from the date of irregular discharge.
If the Veteran fails to report for this examination, consider the tuberculosis to be completely arrested from the date of failure to report for examination.  Apply the provisions of graduated ratings based upon inactivity from this date.
Note:  Compensation payments are based upon the degree of disability, not on the basis of a Veteran’s willingness to accept treatment.

 4.  Exhibit:  Examples of Ratings for Arrested Tuberculosis


Introduction

This exhibit contains four examples of ratings for arrested tuberculosis.

Change Date

December 29, 2007

III.iv.4.F.4.a.  Example 1

Situation:  A Veteran is 30-percent disabled based upon residuals of far advanced, inactive, pulmonary tuberculosis.  The rating for tuberculosis was in effect on August 19, 1968.  The tuberculosis became active on September 10, 2002.
Result:  Based upon the reactivation of pulmonary tuberculosis, reinstate the 100-percent evaluation for active tuberculosis and maintain control to ascertain the date of inactivity.
Coded Conclusion
1. SC (KC PRES)
6701
Tuberculosis, pulmonary, chronic, far advanced, active
30% from 08/01/1964
100% from 09/10/2002

III.iv.4.F.4.b.  Example 2

Situation:  Same facts as in Example 1.  Examination reveals tuberculosis was inactive as of May 10, 2003.
Result:  Continue the 100-percent evaluation for two years after the date of inactivity, followed by graduated reduction to 50 percent thereafter for four years.  Reduce to 30 percent from May 10, 2009, and thereafter based on far advanced lesions.
Coded Conclusion
1. SC (KC PRES)
6701
Tuberculosis, pulmonary, chronic, far advanced, active
30% from 08/01/1964
100% from 09/10/2002

III.iv.4.F.4.c.  Example 3

Situation:  Same facts as in Example 2.  Medical authorities provide notification of the Veteran’s failure to submit to examination for treatment purposes.  The notice of proposed adverse action advised that payments would be reduced effective June 1, 2004, but the date of last payment at the expiration of the due process period was July 1, 2004.
Result:  Reduce the evaluation for pulmonary tuberculosis to 50 percent effective the date of last payment and to 30 percent four years later.
Coded Conclusion
1. SC (KC PRES)
6721
Tuberculosis, pulmonary, chronic, far advanced inactive
100% from 05/10/2003
50% from 07/01/2004
30% from 07/01/2008

III.iv.4.D.4.d.  Example 4

Situation:  Same facts as in Example 3.  Medical authorities provide notification the Veteran has reported for examination on March 10, 2005.  The tuberculosis remains inactive.
Result:  Reinstate the 100-percent evaluation and reduce the evaluation to 50 percent two years after the date of inactivity of pulmonary tuberculosis.  Reduce to 30 percent four years later.
Coded Conclusion
1. SC (KC PRES)
6721
Tuberculosis, pulmonary, chronic, far advanced inactive
100% from 05/10/2003
50% from 05/10/2005
30% from 05/10/2009

5.  Sleep Apnea and Related Disabilities


Introduction

Change Date
February 19, 2019

III.iv.4.F.5.a.  Sleep Apnea and Sleep Studies

Receipt of medical evidence disclosing a diagnosis of sleep apnea without confirmation by a sleep study is sufficient to trigger the duty to assist for scheduling an examination if the other provisions of 38 CFR 3.159(c)(4) have been satisfied.  However, such evidence is not sufficient to award SC for sleep apnea.
When clinical examination leads to the conclusion that symptoms of sleep apnea are present, the subsequent diagnosis of sleep apnea must be confirmed by sleep study for compensation purposes.
  • Do not establish SC for sleep apnea that has not been confirmed by a sleep study.
  • However, if clinical indicators of sleep apnea are not found on examination, a sleep study is not required to rule out the sleep apnea diagnosis.
Important:  Accept a home sleep study only if
  • it has been clinically determined that the Veteran can be appropriately evaluated by a home sleep study, and
  • a competent medical provider has evaluated the results.
Reference:  For more information about types of medical providers qualified to provide medical evidence, see M21-1, Part III, Subpart iv, 3.D.2.

III.iv.4.F.5.b.Evaluating Sleep Apnea

Evaluate sleep apnea using the criteria in 38 CFR 4.97, DC 6847 (sleep apnea syndromes (obstructive, central, mixed).
When determining whether the 50-percent criteria are met, the key consideration is whether use of a qualifying breathing assistance device is required by the severity of the sleep apnea.
There are two related considerations, which are

III.iv.4.F.5.c.  Qualifying Devices for Sleep Apnea Treatment

38 CFR 4.97, DC 6847 lists a CPAP machine as an example of a breathing assistance device for treatment of sleep apnea which is required for assignment of the 50 percent evaluation.
Other qualifying breathing assistance devices include
  • other positive airway pressure machines (automatic positive airway pressure device (APAP); bilevel positive airway pressure device (BiPAP))
  • nasopharyngeal appliances (nasal dilators; nasopharyngeal stents)
  • oral appliances (mandibular advancement devices (MAD); tongue-retaining mouthpieces), and
  • implanted genioglossal nerve stimulation devices.
Note:  Positive airway pressure machines may also be called non-invasive positive pressure ventilation (NIPPV) or non-invasive ventilation (NIV).

III.iv.4.F.5.d.  Required Use of a Breathing Assistance Device

Assignment of the 50-percent evaluation for sleep apnea under 38 CFR 4.97, DC 6847 entails the required use of a breathing assistance device.  Consider the factors below in determining whether the criteria for required use of a breathing assistance device are satisfied.
  • Use of a device absent a medical determination that the device is necessary does not qualify.  The regulation requires that the device be necessary, and this is a medical question.
  • If the competent medical evidence of record shows that use of a qualifying breathing assistance device is medically required, the fact that the claimant is not actually using it as prescribed is not relevant.

III.iv.4.F.5.e.Processing Claims for Increase in Sleep Apnea

Follow the steps in the table below to process a claim for increase in sleep apnea.
Step
Action
1
Is there a sleep study confirming the diagnosis of sleep apnea?
  • If yes, go to Step 6.
  • If no, go to Step 2.
2
Has SC for sleep apnea been in effect for 10 years or more?
  • If yes, go to Step 6.
  • If no, go to Step 3.
3
  • Request an examination with sleep study to confirm the diagnosis.
  • Go to Step 4.
4
Does the sleep study confirm the diagnosis of sleep apnea?
  • If yes, go to Step 6.
  • If no, go to Step 5.
5
Prepare a proposal to sever SC for sleep apnea in accordance with38 CFR 3.105(d).
Reference:  For more information on preparing proposed rating decisions, see M21-1, Part III, Subpart iv, 8.B.1.
6
Perform any additional development as necessary, continue SC for sleep apnea, and assign an evaluation based on the evidence of record.

III.iv.4.F.5.f. Considering UARS 

Upper airway resistance syndrome (UARS) represents a progression toward the potential development of sleep apnea, caused by snoring.  However, UARS, in and of itself, does not meet the criteria of sleep-disordered breathing that defines sleep apnea and is not considered a ratable disability for compensation purposes.
In order to dispose of a claim for SC where only an assessment of UARS is shown, the rating activity must
  • deny SC in the absence of a diagnosed chronic disability
  • code the issue as analogous to sleep apnea under 38 CFR 4.97, DC 6847, and
  • inform the Veteran that he/she may submit a supplemental claim if a clinical diagnosis of sleep apnea is subsequently confirmed.
Example:
Image of DC on rating codesheet.
References:  For more information on

6.  Respiratory Tract Infections


Introduction

Change Date
January 31, 2018

III.iv.4.F.6.a.  Types of Chronic Upper Respiratory Tract Infections

Chronic upper respiratory tract infections include
  • chronic rhinitis
  • chronic sinusitis
  • chronic tonsillitis, and
  • chronic laryngitis.

III.iv.4.F.6.b.  Identifying the Cause of Coexisting Chronic Upper Respiratory Tract Infections

The cause of two or more coexisting chronic upper respiratory tract infections is commonly the same infectious process.  However, if two or more chronic infections persist over a period of years, give the probability of causation by separate types of organisms due weight.

III.iv.4.F.6.c.  Continuous Upper Respiratory Tract Infections That First Manifest After Discharge

If all respiratory conditions do not originate in service, there must be evidence of a fairly continuous infection in one or more parts of the upper respiratory tract to warrant SC for other conditions first manifest after discharge.
Carefully consider the character of the infection and possible intervening causes.

III.iv.4.F.6.d.  Relationship Between Upper and Lower Respiratory Tract Infections

There may be a close relationship between disease of the upper respiratory tract and a subsequently-developing chronic process in the lower respiratory tract, especially in the bronchi.

7.  Other Respiratory Disabilities


Introduction

Change Date
January 31, 2018

III.iv.4.F.7.a.  Deviated Nasal Septum

SC cannot be granted for a deviation of the nasal septum unless trauma is shown.
Reference:  For more information on traumatic nasal septum deviation see 38 CFR 4.97, DC 6502.

III.iv.4.F.7.b.  Sinusitis

Evaluate sinusitis under 38 CFR 4.97, DCs 6510 through 6514.
When applying the higher of two possible evaluations under 38 CFR 4.7, a history of radical surgery or repeated surgeries is not required if the criteria under the rating formula are otherwise met.
Example:  The application of 38 CFR 4.7 results in an evaluation of 50 percent when the evidence shows
  • chronic osteomyelitis, or
  • near constant sinusitis, characterized by
    • headaches
    • pain and tenderness of affected sinus, and
    • purulent discharge, and
  • no evidence of radical surgery or repeated surgery.
Reference:  For more information on the schedule of rating respiratory conditions, see 38 CFR 4.97.

III.iv.4.F.7.c.  Considering Allergic Rhinitis Within Scope of Claimed Sinusitis

When a claim for SC for sinusitis is received but compensation examination reveals a diagnosis of allergic rhinitis and not sinusitis and associates the rhinitis with service, consider allergic rhinitis within scope of the claim for SC for sinusitis.  In this situation
  • do not return the examination for clarification of a diagnosis if the examination is otherwise sufficient
  • grant SC for allergic rhinitis if otherwise supported by the evidence of record, and
  • deny SC for sinusitis, if sinusitis is not shown.
Reminder:  If both sinusitis and rhinitis are shown and the requirements for SC are met for both conditions, grant SC for each condition separately and  combine as usual under 38 CFR 4.25.
Reference:  For more information on considering issues within scope of a claim, see

III.iv.4.F.7.d.  Allergic Rhinitis

38 CFR 3.380 directs that diseases of allergic etiology are not to be disposed of routinely for compensation purposes as constitutional or developmental abnormalities.  When considering SC for allergic rhinitis, consider whether
  • the disability existed prior to service, and
  • whether the disability is chronic and persistent in relation to exposure to and removal from the allergen.
The determination as to service incurrence must be based on the whole evidentiary showing.
Example:  Veteran claims SC for allergic rhinitis.  The nose and sinuses were normal at enlistment with no allergies noted.  During his 20 year military career, the Veteran was treated variably for symptoms of upper respiratory infection, congestion, rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, and seasonal allergies throughout service.  Clear diagnoses of allergies and allergic rhinitis were noted during service including on the retirement physical.  At the compensation examination, the Veteran reported episodic sinusitis and ongoing allergic rhinitis with seasonal symptoms and the use of medications for treatment.  Examination revealed no obstruction or deviation.  No rhinitis or sinusitis were active on examination.  The diagnosis was seasonal allergic rhinitis.
Result:  The Veteran had a long and recurring history of complaints of, treatment for, and diagnosis of allergic rhinitis and upper respiratory symptoms during service.  There is no evidence of a pre-service history of allergic rhinitis.  Veteran is entitled to SC with a noncompensable evaluation for allergic rhinitis as evidence showed incurrence in service.

III.iv.4.F.7.e.Complete Organic Aphonia and SMC

Award special monthly compensation (SMC) if complete organic aphonia results in the constant inability to communicate by speech.
Reference:  For more information on awarding SMC for organic aphonia, see

III.iv.4.F.7.f.  Spontaneous Pneumothorax

Provide an evaluation of 100 percent following episodes of total spontaneous pneumothorax as of the date of hospital admission, continuing for three months from the first day of the month after hospital discharge.
Evaluate pneumothorax under 38 CFR 4.97, DC 6843.

III.iv.4.F.7.g.GSWs of MGs I to IV and XXI

When evaluating gunshot wounds (GSWs) of muscle groups (MGs) I through IV and MG XXI, an evaluation under the general rating formula for restrictive lung disease, which covers 38 CFR 4.97, DCs 6840 through 6845must be considered.
A minimum evaluation of 20 percent must be assigned if there is
  • a bullet or missile retained in the lung
  • pain or discomfort on exertion
  • scattered rales
  • limitation of excursion of diaphragm, or
  • limitation of excursion of lower chest expansion.
Notes:
  • Separate ratings may be awarded for MGs I through IV and ratings for respiratory impairment.
  • A GSW of MG XXI will not be separately evaluated from the respiratory disability under restrictive lung disease criteria.  Assign a single evaluation for injury to MG XXI and any respiratory impairment.
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