Overview
In This Section |
This section contains the following topics:
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1. General Information on Neurological and Convulsive Disorders
Introduction |
This topic contains general information about neurological and convulsive disorders, including
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Change Date |
February 2, 2018
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III.iv.4.N.1.b. Identifying Epilepsy |
Seizures must be witnessed or verified by a physician to warrant service connection (SC) for epilepsy. Verification may be by an electroencephalogram (EEG), which measures electrical activity in the brain.
A physician does not have to witness an actual seizure before a diagnosis of epilepsy can be accepted for evaluation purposes. Verification by a physician based upon factors other than observing an actual seizure is sufficient.
References: For more information on
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III.iv.4.N.1.c. Evaluating Progressive Spinal Muscular Atrophy |
Progressive muscular atrophy, 38 CFR 4.124a, diagnostic code (DC) 8023, refers to progressive spinal muscular atrophy, which is a disease of the spinal cord.
Progressive muscular atrophy is subject to presumptive SC under 38 CFR 3.309(a)because it is an organic disease of the nervous system.
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III.iv.4.N.1.d. Other Organic Diseases of the Nervous System Under 38 CFR 3.309(a) |
For purposes of establishing presumptive SC for a chronic disease under 38 CFR 3.307, the term other organic diseases of the nervous system in 38 CFR 3.309(a) includes any commonly recognized neurological disease (such as may be found in a valid contemporary medical treatise), which is not otherwise specifically enumerated under 38 CFR 3.309(a). This includes, but is not limited to, the following conditions:
Important: If there is uncertainty as to whether or not a claimed disability may be considered as an organic disease of the nervous system for purposes of 38 CFR 3.309(a), send the case to Compensation Service’s Advisory Review Staff for guidance.
References: For more information on
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III.iv.4.N.1.e. SC of Vertigo |
Carefully consider the evidence of record when considering SC for vertigo. Vertigo is generally considered a symptom of another disability such as traumatic brain injury (TBI), Meniere’s disease, vestibular neuritis/labyrinthitis, MS, stroke or tumor.
When the disability manifested by vertigo is adequately identified, SC should be established for that diagnosis rather than for “vertigo.” However, SC can be established for “vertigo” in the absence of a known or established underlying etiology if there is
References: For more information on
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2. TBI
Introduction |
This topic contains information about TBI, including
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Change Date
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June 22, 2018
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III.iv.4.N.2.a. Definition: TBI |
The term traumatic brain injury (TBI) means the physical, cognitive and/or behavioral/emotional residual disability resulting from an event of external force causing an injury to the brain.
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III.iv.4.N.2.b. TBI Events |
The TBI event is a traumatically induced structural injury and/or physiological disruption of brain function resulting from an external force indicated by at least oneof the following clinical signs immediately following the event:
Notes:
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III.iv.4.N.2.c. External Force for the Purpose of TBI Events |
External force means any of the following events:
Note: TBI events may occur during combat or non-combat situations (such as a motor vehicle accident, fall, or personal assault).
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III.iv.4.N.2.d. TBI Residuals |
The resultant disabling effects of a TBI event beyond those that follow immediately from the acute injury to the brain are known as TBI residuals or TBI sequelae.
The signs and symptoms of TBI residuals can be organized into the three main categories of physical, cognitive, and behavioral/emotional residuals for evaluation purposes. Examples of TBI residuals in each of the three categories may include, but are not limited to, those listed below.
Note: TBI residuals can resolve in a short period of time or can persist chronically or even permanently. Chronic TBI residuals may include some or all of the clinical signs that developed immediately during the TBI event. Others (such as seizures or spasticity) may have a delayed onset.
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III.iv.4.N.2.e. Determining the Issues in TBI Cases |
A claim for SC for TBI may also be worded as a claim for “head injury,” or “concussion.” A claim document mentioning any of the above must be sympathetically read and understood as a claim for all identifiable TBI residuals that can be attributed to one or more TBI events.
A claim for “combat injuries,” assault, automobile accident, fall, or other injurious events may also raise the issue of a TBI if there was an injury to the head.
As recognized by 38 CFR 4.124a, DC 8045, the external force of a claimed TBI event may result not only in brain injury but also in physical or psychological disorders distinct from brain injury residuals. An explosion, for example, may cause burns, muscle injuries, orthopedic injuries including amputations, and posttraumatic stress disorder in addition to a brain injury. A TBI claim mentioning a specific traumatic event must be sympathetically read as a claim for SC for alldisabling chronic residuals of the event.
Reference: For more information on determining the issues, see M21-1, Part III, Subpart iv, 6.B.
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III.iv.4.N.2.f. SC of TBI Residuals |
When signs and symptoms are identified as TBI residuals and associated with an in-service TBI event, 38 CFR 3.303 allows for SC on a direct basis.
A medical opinion is necessary when the medical evidence of record does notshow a clear-cut etiology for a sign or symptom claimed as a delayed effect.
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III.iv.4.N.2.g. Evaluation of TBI Residuals |
Evaluate service-connected (SC) TBI residuals under 38 CFR 4.124a, DC 8045.
In every case, one evaluation should be assigned using the highest level of impairment assigned to any facet contained in the table “Evaluation of Cognitive Impairment and Other Residuals of TBI not Otherwise Classified,” which has been incorporated into the Veterans Benefits Management System – Rating (VBMS-R).
Additional evaluations may be appropriate to assign as provided in M21-1, Part III, Subpart iv, 4.N.2.h and i.
Note: A medical classification of severity of the TBI at the time of the acute traumafrom the TBI event has no bearing on evaluation for Department of Veterans Affairs (VA) compensation purposes. It is not an evaluation factor and is not relevant to the application of the benefit of the doubt rule. Do not imply or state that initial severity classification was given weight in assigning a disability evaluation.
References: For more information on
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III.iv.4.N.2.h.Multiple Evaluations and Pyramiding in TBI Cases |
In addition to the evaluation for TBI manifestations under the table “Evaluation of Cognitive Impairment and Other Residuals of Residuals of TBI Not Otherwise Classified” in 38 CFR 4.124a, DC 8045 (and also incorporated into VBMS-R), manifestations of a comorbid mental, neurologic or other physical disorder can be separately evaluated under another DC if there is a distinct diagnosis – even if based on subjective symptoms – and no more than one evaluation is based on the same manifestation(s).
Follow the policy in the table below.
References: For more information on
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III.iv.4.N.2.i. Evaluating TBI and Co-Morbid Symptoms/ Conditions |
Use the table below when evaluating TBI and co-morbid symptoms and/or conditions.
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III.iv.4.N.2.j. Example of Evaluating TBI With Co-Morbid Conditions |
Situation: VA examination shows the Veteran has numerous behavioral/emotional symptoms (depression that severely affects his work and his family relationships, frequent suicidal thoughts, confusion, apathy, and unpredictability) and meets the diagnostic criteria for both TBI and for major depression. The examiner was unable to differentiate which symptoms are associated with TBI and which with major depression. In addition, the TBI examination found multiple physical complaints related to TBI, including vertigo, sensitivity to light, blurred vision, and subjective headaches. Evaluation under 38 CFR 4.130 criteria would result in the higher evaluation for the behavioral/emotional symptoms due to TBI and major depression.
Result: Assign an evaluation for the behavioral/emotional residuals under 38 CFR 4.130, DC 9434. Assign a separate evaluation under 38 CFR 4.124a, DC 8045 for the remaining physical symptoms and combine the evaluations under 38 CFR 4.25.
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III.iv.4.N.2.k. Opinion Evidence and Separate Evaluations of TBI and a Mental Disorder |
Ensure that sufficiently clear and unequivocal medical opinion evidence exists in the claims folder whenever there is a question of whether TBI and a mental disorder are distinct and can be separately evaluated. Veterans Benefits Administration (VBA) decision makers are not qualified to make such determinations.
The opinion may be provided by either an examiner assessing the TBI or an examiner assessing the mental disorder as long as the individual offering the opinion is properly qualified.
If a medical provider cannot make the required determination without resorting to mere speculation, then careful consideration must be given to whether that statement can be accepted under Jones v. Shinseki, 23 Vet.App. 382 (2010).
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III.iv.4.N.2.l. Additional TBI Signs or Symptoms Upon Reevaluation |
When considering a claim for reevaluation of TBI, do not automatically concede that a new sign, symptom or diagnosis is a residual of TBI simply because it is listed in M21-1, Part III, Subpart iv, 4.N.2.d or in the evaluation criteria.
If there is not competent evidence that the sign, symptom or diagnosis is associated with the SC TBI, obtain medical clarification.
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III.iv.4.N.2.m. TBI and SMC |
Brain injuries may be associated with loss of use of an extremity, sensory impairments, erectile dysfunction, need for regular aid and attendance (A&A) (including need for protection from hazards of the daily living environment due to cognitive impairment), and being factually housebound or statutorily housebound.
Carefully consider eligibility for special monthly compensation (SMC) when evaluating TBI residuals.
References: For more information on
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III.iv.4.N.2.n. Temporary Total Evaluations and TBI |
In cases of recently discharged Veterans, consider the applicability of a temporary 50-percent or 100-percent prestabilization evaluation under the provisions of 38 CFR 4.28.
Lengthy VA hospitalizations or surgeries with convalescence may also implicate consideration of eligibility for temporary total evaluation under 38 CFR 4.29 and 38 CFR 4.30.
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III.iv.4.N.2.o. Training and Signature Requirements for TBI Decisions |
All decisions that address TBI as an issue, including rating decisions, Statements of the Case (SOCs), and Supplemental Statements of the Case (SSOCs), mustonly be worked/reviewed by a Rating Veterans Service Representative (RVSR) or Decision Review Officer (DRO) who has completed the required TBI Training Performance Support System module.
Decisions for TBI require two signatures until a decision maker has demonstrated an accuracy rate of 90 percent or greater based on a review of at least 10 TBI cases.
References: For more information on
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III.iv.4.N.2.p. Applicability of 38 CFR 3.114(a) in TBI Cases |
The rating criteria for evaluating TBI were changed effective October 23, 2008.
Under Note (5) of 38 CFR 4.124a, DC 8045, a Veteran whose residuals of TBI are rated under a version of the diagnostic criteria in effect before October 23, 2008, may request review under the current regulation irrespective of whether his or her disability has worsened since the last review. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review, applying 38 CFR 3.114(a) as applicable. However, in no case will the award be effective before October 23, 2008.
Reference: For more information on liberalizing changes of law and VA issuances, see M21-1, Part III, Subpart iv, 5.C.7.
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III.iv.4.N.2.q. TBI Flash |
Ensure that the Traumatic Brain Injury flash has been added in all cases involving claims for TBI by reviewing the VBMS profile screen.
The flash should be added when the claim is received. It remains on the corporate record if TBI is granted and is removed if TBI is denied.
Reference: For more information on claimant flashes, see
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III.iv.4.N.2.r. Anoxic Brain Injury |
Anoxic brain injury is a condition resulting from a severe decrease in the oxygen supply to the brain that may be due to any of a number of possible etiologies, including trauma, strangulation, carbon monoxide poisoning, stroke, and many others.
As anoxic brain injury does not have its own unique DC in the rating schedule, it can be rated analogously, depending on the specific medical findings in a particular case.
Use the table below to determine the possible analogous rating.
Important: Follow the guidance in M21-1, Part III, Subpart iv, 4.N.2.h and i when considering the assignment of multiple evaluations for residuals.
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3. Secondary Conditions Associated with TBI
Introduction |
This topic contains information on secondary conditions associated with SC TBI, including
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Change Date |
May 9, 2016
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III.iv.4.N.3.a. Secondary SC under 38 CFR 3.310 |
38 CFR 3.310(d) was amended on December 17, 2013, to establish an association between TBI and certain illnesses.
In absence of clear evidence to the contrary, the following five diagnosable illnesses are held to be a secondary result of TBI:
Entitlement to secondary SC for these TBI-related conditions in 38 CFR 3.310(d)depends upon the initial severity of the TBI and the period of time between the injury and onset of the secondary illness.
Important: There is no need to obtain a medical opinion to determine whether the above conditions are associated with TBI when there is a TBI of a qualifying degree of severity.
Notes:
References: For more information on
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III.iv.4.N.3.b. Evaluating the Initial Severity of TBI |
For purposes of determining the initial severity of the TBI, consider the factors from the table in 38 CFR 3.310(d). Review medical records and lay statements for evidence of
Reference: For more information on verifying in-service blast injuries, see M21-1, Part III, Subpart iv, 4.N.3.e.
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III.iv.4.N.3.c. Using the TBI Initial Severity Table in 38 CFR 3.310 |
The TBI does not need to meet all the criteria listed under a certain severity level in order to classify the TBI under that severity level.
If the Veteran’s TBI meets the criteria in more than one severity level, evaluate the TBI at the highest level in which a criterion is met.
Because “normal structural imaging,” “abnormal structural imaging” and “AOC greater than 24 hours” may be found at more than one severity level, evaluate severity based on other criteria in the table. If no other criteria are present, then determine the level of severity as follows:
If the level of severity cannot be determined based on the available evidence, then apply the provisions of 38 CFR 3.310 (a) and (b) and order a VA examination/medical opinion as necessary.
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III.iv.4.N.3.d.
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Evidence that may be relevant in ascertaining the initial severity of TBI symptoms includes
Note: The evidence that establishes the initial severity of the TBI does not necessarily have to be contemporaneous to the injury as long as it relates to the condition of TBI at or shortly after the time of the injury.
Example: A Korean War Veteran submits a claim for SC for Parkinsonism secondary to his SC TBI. The Veteran’s discharge examination from 1954 mentions a history of TBI in service. However, it does not contain information sufficient to determine the level of severity of the initial TBI injury. The Veteran provides a statement that he experienced a loss of consciousness during the Battle of Chosin Reservoir. A review of prior VA examination reports reveals a history provided by the Veteran that he was told by fellow soldiers that he fell unconscious for almost an hour after two grenades exploded near him.
Analysis: Although service records do not reveal the specific level of TBI during service, the Veteran’s statement is credible, consistent with circumstances of his service, and therefore sufficient to determine that he experienced a moderate level of TBI during service.
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III.iv.4.N.3.e. Registry for Verifying Blast Injuries |
The U.S. Army Medical Research and Materiel Command Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) has developed a registry of service members who were within 50 feet of a blast since mid-2010.
When existing Department of Defense records, to include STRs, are not sufficient to verify exposure to a blast injury that occurred since mid-2010, Compensation Service will contact JTAPIC to determine if there is a record of exposure.
Important: E-mail Compensation Service at VAVBAWAS/CO/211 Policy Staff if exposure to an in-service blast injury from mid-2010 to the present cannot be verified. Include the following information in the e-mail:
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III.iv.4.N.3.f. Determination of Diagnosable Conditions as Secondary to TBI |
Use the table below to determine secondary SC for conditions listed in 38 CFR 3.310(d).
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III.iv.4.N.3.g. Considerations When Establishing Secondary SC |
When evaluating TBI-related secondary conditions, avoid pyramiding when considering the initial TBI evaluation and symptoms that are now associated with the five secondary conditions. Also, consider Notes 1 and 2 under 38 CFR 4.124a, DC 8045, while ensuring that the claimant receives the highest overall evaluation under the provisions of 38 CFR 4.25 (Combined Ratings Table).
Depending on the most advantageous combined evaluation, it is permissible to reduce an existing TBI evaluation as long as the overall evaluation of both TBI and the separate secondary SC condition is not reduced. Use the combinator tool in VBMS-R to determine the combined evaluation of TBI and the secondary SC condition. Thoroughly explain the decision narrative in the rating decision.
Use the table below to consider symptoms which apply to both TBI and the secondary conditions.
Reference: For more information on evaluating TBI residuals, see M21-1, Part III, Subpart iv, 4.N.2.g.
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III.iv.4.N.3.h.Action When Evidence Shows a 38 CFR 3.310(d) Condition |
Use the table below to determine how to proceed when evidence shows one of the five diagnosable conditions in 38 CFR 3.310(d).
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III.iv.4.N.3.i. Determining Effective Dates for Secondary Conditions |
The rule authorizing VA to establish the five secondary TBI-related conditions in 38 CFR 3.310 is effective, January 16, 2014.
This rule will be applied to all cases pending before VA on or after, January 16, 2014, and does constitute a liberalizing VA regulation under 38 U.S.C. 5110(g) and38 CFR 3.114. Apply these principles when determining effective dates and retroactive benefits.
Reference: For more information on 38 CFR 3.114(a), see M21-1, Part III, Subpart iv, 5.C.7.
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4. Peripheral Nerves
Introduction |
This topic contains information on evaluating peripheral nerves, including
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Change Date |
November 16, 2017
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III.iv.4.N.4.a.Regulations for Evaluating Peripheral Nerves |
38 CFR 4.124a, DC 8510-8730 provides evaluation levels for complete paralysis and incomplete paralysis, neuritis or neuralgia of peripheral nerves.
At the beginning of the DCs for the peripheral nerves, the regulation also states that “incomplete paralysis” anticipates substantially less impaired function than described for complete paralysis of the nerve. When impairment is wholly sensory, the evaluation should be that specified for the mild, or at most, the moderate degree of incomplete paralysis for the nerve.
The regulations listed below also provide guidance on evaluating peripheral nerves.
38 CFR 4.120 provides that when rating peripheral nerve injuries and residuals consider the relative impairment of motor function, trophic changes, and/or sensory disturbances. Attention should be given to the site and character of the injury.
38 CFR 4.123 provides several principles relating to peripheral nerves.
38 CFR 4.124 provides that the maximum evaluation for neuralgia, characterized usually by a dull and intermittent pain in the distribution of a nerve, should be the evaluation provided for moderate incomplete paralysis of the nerve under theapplicable DC.
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III.iv.4.N.4.b. 38 CFR 4.124a Guidance on Evaluating Completely Sensory Peripheral Nerve Impairment |
In cases where a peripheral nerve disability is only manifested by sensory impairment, 38 CFR 4.124a directs decision makers to assign the evaluation corresponding with the mild or at most the moderate degree of impairment.
To make a choice between mild and moderate, consider the evidence of record and the following guidelines:
Important: This provision does not mean that if there is any impairment that is non-sensory (or involves a non-sensory component) such as a reflex abnormality, weakness or muscle atrophy, the disability must be evaluated as greater than moderate. Significant and widespread sensory impairment may potentially indicate the same or even more disability than a case involving a minimally reduced or increased reflex or minimally reduced strength.
References: For more information on
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III.iv.4.N.4.c. Assigning Level of Incomplete Paralysis, Neuritis or Neuralgia |
The table below provides general guidelines for each level of incomplete paralysis of the upper and lower peripheral nerves.
Notes:
Reference: For more information on evaluating peripheral nerves, see thePeripheral Nerve Evaluation Matrix.
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III.iv.4.N.4.d. Considering the Complete Findings When Evaluating Incomplete Paralysis |
Evaluation Builder entries must be based upon the complete findings of the Disability Benefits Questionnaire (DBQ) and/or evidentiary record including
Do not base the entries solely upon the examiner’s assessment of the level of incomplete paralysis.
The examiner’s clinical assessment of the extent of incomplete paralysis, as indicated on the DBQ, may be inconsistent with or appear to contradict the objective findings that are documented in other sections of the DBQ or other evidence of record.
Important: The rating activity, not the examining medical professional, determines whether the overall evidentiary record shows the severity of the condition meets the criteria for a classification of mild, moderate, moderately severe, or severe.
Example 1: An examiner assesses the peripheral nerve disability as “mild incomplete paralysis.” However, the DBQ shows muscle weakness, atrophy, and diminished reflexes, which are clearly demonstrative of more than mild incomplete paralysis. In this case, the complete evidentiary record shows the condition is more than mild under guidance contained in 38 CFR 4.124 and therefore warrants a higher evaluation.
Example 2: An examiner renders an assessment of “severe incomplete paralysis” when the objective test results are wholly sensory. Therefore the condition warrants an evaluation no higher than moderate incomplete paralysis under 38 CFR 4.124a.
References: For more information on
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III.iv.4.N.4.e.Nerve Branches of the Lower Extremities for Which Separate Evaluations May Be Assigned |
The table below lists the five nerve branches of the lower extremities for which separate evaluations may be assigned. See M21-1, Part III, Subpart iv, 4.N.4.f for rating guidance on assigning separate evaluations for nerve conditions of the lower extremities.
To assist in evaluating these nerves, the table below also includes any associated nerves in each branch, corresponding DCs under 38 CFR 4.124a, and the general functions covered by each nerve branch.
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III.iv.4.N.4.f. Assigning Separate Evaluations for Lower Extremity Peripheral Nerves |
Unlike the upper extremities, separate evaluations of the lower extremities may be assigned for symptoms that are separate and distinct, do not overlap, and are attributed to different lower extremity nerves. This means that separate evaluations are warranted when symptoms arise from any of the five nerve branches listed in the table in M21-1, Part III, Subpart iv, 4.N.4.e.
If symptoms arise from within the same nerve branch of any of the five individual nerve branches in the lower extremity, assigning separate evaluations for those symptoms are not warranted as this would constitute pyramiding.
Example 1: Separate Evaluations Warranted
A Veteran has severe incomplete paralysis of the common peroneal nerve and mild incomplete paralysis of the femoral nerve. Assign separate evaluations of 30 percent under 38 CFR 4.124a, DC 8521 and 10 percent under 38 CFR 4.124a, DC 8526.
Analysis: The common peroneal nerve is part of the sciatic branch and the femoral nerve is part of the femoral branch. The functions for these branches are separate and distinct and therefore warrant separate evaluations.
Example 2: Separate Evaluations Not Warranted
A Veteran has severe incomplete paralysis of the common peroneal nerve under38 CFR 4.124a, DC 8521 and moderate incomplete paralysis of the tibial nerve under 38 CFR 4.124a, DC 8524. In this case, a single 30-percent evaluation is assigned under 38 CFR 4.124a, DC 8521.
Analysis: Both of these nerves are part of the same sciatic branch, and therefore the functions associated with these nerves are not separate and distinct. The 30-percent evaluation shall be assigned under 38 CFR 4.124a, DC 8521 since it represents the predominant disability.
References: For more information about
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III.iv.4.N.4.g. Determining Individual Nerves Affected in the Upper and Lower Extremities When Evaluating Disabilities |
When evaluating peripheral nerve disabilities of the upper and lower extremities, the rating activity must conduct a thorough review of the medical evidence of record to determine the individual nerve(s) affected.
VA examiners are required, to the extent possible, to select the individual nerves affected when completing DBQs. However, the examiner may not necessarily conduct a review of all previous clinical records or perform comprehensive tests to pinpoint the exact nerve and/or symptoms attributable to that nerve.
Important:
Examiner: Please identify the specific nerve(s) affected. If you are unable to identify the specific nerve(s), please provide a rationale in the Remarks section. Thank you.
Follow the guidance in the table below when reviewing medical evidence pertaining to peripheral nerve disabilities of the upper and lower extremities.
Note: The nerve branches and general functions of the nerve branches of the lower extremities are described in the table found in M21-1, Part III, Subpart iv, 4.N.4.e.
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III.iv.4.N.4.h. EMG and Other Tests for Peripheral Nerve Conditions |
Electromyography (EMG) results are required for evaluations of peripheral nerve disabilities unless there is a previous EMG test of record or the record contains sufficient clinical evidence to determine the extent of paralysis in the peripheral nerve.
As noted in the Peripheral Nerves DBQ, EMG studies are usually rarely required to diagnose specific peripheral nerve conditions in the appropriate clinical setting and, if EMG studies are in the medical record and reflect the Veteran’s current condition, repeat studies are not indicated.
Important: Ultimately, it is the role of the rating activity to determine if the examination was sufficient to confirm the question and extent of peripheral nerve involvement.
Note: Other clinical findings that may be sufficient to document a peripheral nerve disability include
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III.iv.4.N.4.i. Applying the Amputation Rule to Peripheral Nerve Disabilities |
In determining whether the amputation rule under 38 CFR 4.68 applies to peripheral nerve evaluations, decision makers must consider the etiology of the peripheral nerve disability.
If the peripheral nerve disability is associated with a musculoskeletal injury or amputation, follow the guidance in &M21-1, Part III, Subpart iv, 4.B.7.j regarding the application of the amputation rule.
When peripheral nerve disabilities are not associated with a musculoskeletal injury, such as diabetic neuropathy, the amputation rule does not apply.
Reference: For more information on evaluating peripheral nerve injuries associated with a muscle injury, see 38 CFR 4.55.
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5. MS
Introduction |
This topic contains information about MS, including
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Change Date |
June 15, 2015
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III.iv.4.N.5.a. Definition: MS |
Multiple sclerosis (MS) is a slowly progressive central nervous system disease, and is characterized by
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III.iv.4.N.5.b. Evaluating a Residual MS Disability 30 Percent or More |
In cases of MS
Notes:
Important: Readjudicate cases previously evaluated as a single disability as they are encountered under the procedure outlined above.
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III.iv.4.N.5.c. Example of Evaluating Residual MS Disability 30 Percent or More |
This exhibit contains an example of evaluating a residual MS disability 30 percent or more.
43. Bilateral Factor of 1.9% added for diagnostic codes 8521 and 8521
Note: SMC coding is 01-01-00-00-1.
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III.iv.4.N.5.d.Presumptive SC for MS |
Presumptive SC may be established for MS if the disease becomes manifest within seven years from the date of separation.
Reference: For more information on requirements for establishment of presumptive SC, see 38 CFR 3.307(a) and 38 CFR 3.309.
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6. ALS
Introduction |
This topic contains information about ALS, including
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Change Date |
July 8, 2016
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III.iv.4.N.6.a. Definition: ALS |
Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease, is a neuromuscular disease that causes degeneration of nerve cells in the brain and spinal cord, resulting in muscle weakness, muscle atrophy, and spontaneous muscle activity.
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III.iv.4.N.6.b. Establishing Presumptive SC for ALS |
Effective September 23, 2008, 38 CFR 3.318 established a presumption of SC for ALS manifested at any time after discharge or release from active military, naval, or air service.
Exceptions: SC will not be established if
In Bowers v. Shinseki, 748 F.3d. 1351 (Fed. Cir., 2014), the Federal Circuit held that the presumption of SC for ALS only applies to individuals having attained Veteran status by virtue of having performed active military, naval, or air service. National Guard service that did not meet the requirements of active military, naval, or air service did not qualify for the presumption. Active duty for training of 90 days did not qualify unless the individual was disabled (or died) as a result of a disease or an injury incurred or aggravated in the line of duty.
Note: Primary lateral sclerosis (PLS) is not considered to be a qualifying disease under 38 CFR 3.318. Because PLS and ALS are diseases of the nervous system and both affect motor neurons, treating physicians may not be able to identify whether the Veteran has PLS or ALS in the initial stages. If the diagnosis is uncertain after reviewing the medical evidence, request a medical opinion with examiner review of all pertinent evidence in the claims folder.
This was considered a liberalizing regulation. Therefore consider the application of38 CFR 3.114(a) when granting presumptive SC for ALS under the provisions of 38 CFR 3.318.
Reference: For more information on liberalizing changes of law and VA issuances, see M21-1, Part III, Subpart iv, 5.C.7.
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III.iv.4.N.6.c. Assigning a 100 Percent Minimum Evaluation for ALS |
ALS is evaluated under 38 CFR 4.124a, DC 8017.
Effective January 19, 2012, the diagnostic criteria for ALS was amended in 38 CFR 4.124a to provide a 100-percent evaluation for any Veteran with SC ALS. A diagnosis of ALS alone is sufficient to support an evaluation of 100 percent. A total disability evaluation is the minimum evaluation to be assigned for ALS because of the possibility of SMC and automatic entitlement to ancillary benefits.
Note: This rule will be applied to all cases pending before VA on or after, January 19, 2012, and does constitute a liberalizing VA regulation under 38 U.S.C. 5110(g)and 38 CFR 3.114 for the purpose of determinations of effective dates and retroactive benefits.
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III.iv.4.N.6.d. Evaluation Guidelines for ALS |
Determine the proper evaluation for all complications of ALS prior to coding a single 100-percent evaluation under 38 CFR 4.124a, DC 8017. Refer to the table below for guidance.
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III.iv.4.N.6.e. ALS and Ancillary Benefits |
Consider eligibility for SMC and/or other ancillary benefits in all ALS cases.
References: For more information on
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7. Migraine Headaches
Introduction |
This topic contains information on migraine headaches, including
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Change Date |
June 15, 2015
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III.iv.4.N.7.a. Evaluation Criteria for Migraine Headaches |
Migraine headaches are evaluated under the criteria of 38 CFR 4.124a, DC 8100. Evaluations depend primarily on the frequency of attacks and the degree to which symptoms are prostrating. The extent to which the headaches cause work impairment is also a factor and is considered for the 50-percent evaluation.
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III.iv.4.N.7.b. DC 8100 Terminology: Prostrating and Completely Prostrating |
Prostrating, as used in 38 CFR 4.124a, DC 8100, means “causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities.”
Completely prostrating as used in 38 CFR 4.124a, DC 8100, means extreme exhaustion or powerlessness with essentially total inability to engage in ordinary activities.
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III.iv.4.N.7.c. The Role of Medical Evidence in Establishing the Fact of Prostration |
Although prostration is substantially defined by how the disabled individual subjectively feels and functions when having migraine headache symptoms, medical evidence is required to establish that the reported symptoms are due to the SC migraine headaches.
The following is an example of a medical statement that would ordinarily establish the fact of prostration if the medical report and the history provided by the claimant are both credible.
The patient reports symptoms of severe head pain, blurred vision, nausea and vomiting, and being unable to tolerate light or noise, worsened by most activities including reading, writing, and engaging in conversations or physical activities. When experiencing these symptoms, the patient only sleeps or rests. The symptoms reported by the patient are consistent with the diagnosis of migraine headaches and the reported limitations are consistent with those seen in patients suffering from migraine headaches of similar clinical severity.
Note: Medical reports may not use the word “prostration.” However this is an adjudicative determination based on the extent to which the facts meet the definition of the term.
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III.iv.4.N.7.d. Lay Evidence of Prostration from Migraine Headaches |
A claimant’s own testimony regarding his or her symptoms and limitations when having those symptoms can establish prostration as long as the testimony is credible and symptoms are otherwise competently attributed to migraine headaches through medical evidence.
Example: A claimant provides testimony that he/she 1) experiences severe headaches and vomiting when exposed to light; 2) does not engage in any activities when this occurs; and 3) must rest or sleep during these episodes. If there is medical evidence that the claimant’s description of symptoms is in fact symptoms of migraine headaches, a determination that the headaches cause prostration can be made.
Reference: For more information on competency of lay testimony, see
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III.iv.4.N.7.e. DC 8100 Terminology: Severe Economic Inadaptability |
Severe economic inadaptability denotes a degree of substantial work impairment. It does not mean the individual is incapable of any substantially gainful employment. Evidence of work impairment includes, but is not necessarily limited to, the use of sick leave or unpaid absence.
Note: In cases where migraine headaches meet the criterion of severe economic inadaptability and, additionally, the evidence shows that the claimant is incapable of substantially gainful employment due to the headaches, referral for consideration of an extraschedular award of a total evaluation based on individual unemployability is appropriate.
Reference: For more information on severe economic inadaptability, see Pierce v. Principi, 18 Vet.App 440 (2004).
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III.iv.4.N.7.f. DC 8100 Terminology: Less Frequent and Very Frequent |
38 CFR 4.124a, DC 8100 does not define the terms less frequent for the 0- percent criterion or very frequent for the 50-percent criterion. However, the overall rating criteria structure for migraine headaches provides a basis for guidance.
As noted in 38 CFR 4.124a, DC 8100, the 10-percent evaluation specifies average frequency (“averaging one in 2 months over the last several months”), which is half of what is required for a 30-percent evaluation (“on average once a month over the last several months”).
For definitions of the terms less frequent and very frequent, refer to the tablebelow.
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III.iv.4.N.7.g. Frequency Determinations: Types of Proof |
Frequency of migraine headache attacks or episodes is a factual determination. Analyze all evidence in the record bearing on the question.
Probative evidence may include
Note: The absence of treatment reports is not necessarily probative on the question of headache frequency as a claimant may not seek treatment for headaches during every episode.
Reference: For more information on evaluating evidence, including competency and credibility, see M21-1, Part III, Subpart iv, 5.A.
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III.iv.4.N.7.h. Headache Journals |
Headache journals, which routinely and relatively contemporaneously record headache episodes, may be accepted as credible lay testimony regarding
Note: Headaches recorded on non-work days may be used to prove frequency and prostration. However, they will not generally be relevant to work availability, and performance or limitations, which are considerations in determining severe economic inadaptability.
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8. Parkinson’s Disease
Introduction |
This topic contains information on Parkinson’s disease, including
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Change Date |
September 29, 2016
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III.iv.4.N.8.a. Definition: Parkinson’s Disease |
Parkinson’s disease is a chronic, slowly progressive central nervous system disorder characterized by muscular rigidity, a tremor of resting muscles, slow and decreased voluntary movements and positional instability. An outdated term for Parkinson’s disease is paralysis agitans.
Early signs and symptoms of the condition may include:
The condition is characterized by muscle tremors at rest which diminish during movement and are absent during sleep. The tremors are enhanced by emotional tension or fatigue and the hands are most affected. Muscle rigidity may be present without tremors. As the muscle rigidity progresses, movement becomes slow (bradykinesia), decreased or diminished (hypokinesia), and difficult to initiate (akinesia). Other signs and symptoms may include:
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III.iv.4.N.8.b. SC for Parkinson’s Disease |
Parkinson’s disease can be directly incurred in service but in most cases it will be SC on a presumptive or secondary basis.
References: For more information on
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III.iv.4.N.8.c. Evaluating Parkinson’s Disease |
Evaluate Parkinson’s disease using the diagnostic criteria for paralysis agitans under 38 CFR. 4.124a, DC 8004.
Use the same rating guidance as for MS as provided in M21-1, Part III, Subpart iv, 4.N.5.b.
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III.iv.4.N.8.d. SMC and Parkinson’s Disease |
Give careful consideration to SMC in cases of Parkinson’s disease, particularly losses of use and A&A.
References: For more information on
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Historical_M21-1III_iv_4_SecN_1-24-18.docx | May 15, 2019 | 150 KB |
6-22-18_Key-Changes_M21-1III_iv_4_SecN.docx | May 15, 2019 | 96 KB |
Historical_M21-1III_iv_4_SecN_2-2-18.docx | May 15, 2019 | 121 KB |
1-24-18_Key-Changes_M21-1III_iv_4_SecN.docx | May 15, 2019 | 111 KB |
in Chapter 4 Rating Specific Disabilities, Part III General Claims Process, Subpart iv General Rating Process
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