Overview
In This Section |
This section contains the following topics:
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1. Prestabilization Ratings Under 38 CFR 4.28
Introduction |
This topic contains general information on prestabilization ratings under 38 CFR 4.28, including
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Change Date |
December 12, 2018
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IV.ii.2.J.1.a. Purpose of Prestabilization Ratings Under 38 CFR 4.28 |
Prestabilization ratings under 38 CFR 4.28 are provided to assure earliest payment to those Veterans separated from service with a significant unstabilized disability at a time when they are most likely in need and least likely to be self-sufficient.
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IV.ii.2.J.1.c. Duration of the Award Under 38 CFR 4.28 |
Prepare prestabilization ratings under 38 CFR 4.28 as “open ratings.”
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IV.ii.2.J.1.f. Assigning a Prestabilization Rating When Potential Eligibility for SMC Exists |
If there is an indication of possible entitlement to special monthly compensation (SMC), but records are insufficient to make a determination
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IV.ii.2.J.1.g. When a Prestabilization Rating Is Not Appropriate |
Do not assign a
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IV.ii.2.J.1.h. Future Examination Control of Prestabilization Ratings |
When assigning a prestabilization rating, set a future examination control between 6 and 12 months following separation from service for all SC disabilities that are evaluated under 38 CFR 4.28.
Reference: See M21-1, Part III, Subpart iv, 3.C.2, for more information on
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IV.ii.2.J.1.i. Effective Date of Reductions in Combined Evaluations Under 38 CFR 3.105(e) |
Reductions in combined evaluations under 38 CFR 3.105(e) are effective the later of the following:
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IV.ii.2.J.1.j. Expediting Reevaluation of the SC Disability(ies) in Prestabilization Ratings |
After the rating activity receives the report of the examination, completed 6 to 12 months following separation, it must reevaluate the SC disability(ies) to which it assigned a prestabilization rating.
Note: A Veteran who, without good cause, fails to report for the Department of Veterans Affairs (VA) examination scheduled in connection with a prestabilization rating under 38 CFR 4.28 is subject to adjustment of benefits under 38 CFR 3.655.
References: For more information on
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In some cases, VA assigns a 50- or 100-percent prestabilization rating for one or more, but not all, of the same disabilities for which the Veteran received severance pay.
In such cases, assign separate evaluations for the disabilities for which severance pay was awarded which will assist authorization activity in processing an award.
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The provisions of 38 CFR 4.129 operate similarly to 38 CFR 4.28 prestabilization ratings. They both state that qualifying significant disabilities that exist at service discharge will be evaluated at the 50 percent level or higher.
However, under 38 CFR 4.129
Where a qualifying mental disorder is at issue, consider whether the schedular rating available under 38 CFR 4.129 makes a pre-stabilization rating under 38 CFR 4.28 inappropriate.
Reference: For more information on evaluations in cases of service discharge from mental disorders caused by traumatic stress, see
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2. General Information on Hospitalization Ratings Under 38 CFR 4.29
Introduction |
This topic contains general information on hospitalization ratings under 38 CFR 4.29, including
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Change Date |
February 12, 2016
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IV.ii.2.J.2.a. When to Assign Hospitalization Ratings |
Provided a total, 100-percent rating cannot be assigned under other provisions of the rating schedule, assign a temporary 100-percent evaluation under 38 CFR 4.29for
Note: Competency must be addressed when assigning a temporary 100-percent evaluation for a mental disorder under 38 CFR 4.29.
Reference: For more information on addressing competency, see M21-1, Part III, Subpart iv, 8.A.2.a.
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IV.ii.2.J.2.b. Scope of Hospitalization Ratings |
A hospital rating under the provisions of 38 CFR 4.29 can be prompted based on receipt of a specific claim from a Veteran or based on receipt of a Report of Hospitalization at a VA or uniformed services facility.
References: For more information on
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IV.ii.2.J.2.c. Awarding Hospitalization Benefits When Admission Is for a NSC Disability |
Even when hospital admission is for a nonservice-connected (NSC) disability, hospitalization benefits are payable if, during the hospitalization, treatment for an SC disability is initiated and continues in excess of 21 days.
Exception: Treatment for an SC disability that is only coincidental in nature and would not require hospitalization by itself does not qualify.
Example: Medication management for a condition when treatment could otherwise occur outside of hospitalization does not warrant benefits under 38 CFR 4.29.
Reference: For more information on hospitalization ratings when admission is for treatment of an NSC disability, see 38 CFR 4.29(b).
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IV.ii.2.J.2.d. Awarding a Hospitalization Rating for Admission of an Incarcerated Veteran |
If an incarcerated Veteran is confined to a prison hospital for treatment of an SC disability in excess of 21 days, the Veteran may be eligible for hospitalization benefits.
Reference: For information on the effect of imprisonment on benefit payments, see M21-1, Part III, Subpart v, 8.A.
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IV.ii.2.J.2.e. Awarding a Hospitalization Rating for Multiple SC Conditions |
In cases in which two or more SC disabilities exist for which the provisions of 38 CFR 4.29 would apply, increase the evaluation of only one of the disabilities to 100 percent.
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IV.ii.2.J.2.f. When the Provisions of 38 CFR 4.29 Do Not Apply |
Do not apply the provisions of 38 CFR 4.29 when a Veteran
Exceptions:
Notes:
References: For more information on the definition of
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IV.ii.2.J.2.g.Effective Dates of Hospitalization Ratings |
Use the table below to determine the effective date of hospitalization ratings.
References: For more information on
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IV.ii.2.J.2.h. Responsibilities of the Authorization Activity Regarding Computer-Generated Messages |
The following computer-generated message issues every three months when a 100-percent evaluation is assigned under 38 CFR 4.29: Work Item Msg Code 884 – VERIFY HOSP STATUS OF VET – OVER 3 MONTHS.
It is the authorization activity’s responsibility to determine whether the Veteran continues to be hospitalized. The claims folder will be referred to the rating activity for consideration of a schedular 100-percent rating when a Veteran
Note: 800 Series Work Items are for tracking purposes only. Do not complete development, rating, or award actions under an 800 Series Work Item.
Reference: For more information on control of examinations, see M21-1, Part III, Subpart iv, 3.C.
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3. Preparing the Rating Decision for Hospitalization Ratings Under 38 CFR 4.29
Introduction |
This topic contains information on preparing the rating decision for hospitalization ratings under 38 CFR 4.29, including
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Change Date |
July 5, 2015
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IV.ii.2.J.3.a. Duration of Awards Under 38 CFR 4.29 |
Continue the 100-percent rating under 38 CFR 4.29 through the last day of the month in which hospitalization or treatment for the SC disability(ies) terminates.
Notes:
Reference: For more information on the effective date for temporary total ratings under 38 CFR 4.29, please see 38 CFR 3.401(h)(1).
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IV.ii.2.J.3.b. Duration of Extensions of Hospitalization Ratings Allowed Under 38 CFR 4.29 |
The 100-percent rating may initially be extended for one month, two months, or three months, based on a need for convalescence, only when the Veteran received an approved discharge from the hospital.
Following discontinuance of the temporary 100-percent rating, assign the appropriate schedular evaluation for any residual disability.
Notes:
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IV.ii.2.J.3.c. Preparing an Open-Ended Hospitalization Rating Decision |
If a report of the required hospitalization, such as a 21-day certification, is received before the Veteran is discharged from the hospital, prepare an open-ended rating.
References: For more information on
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IV.ii.2.J.3.d. Following Up on an Open-Ended Hospitalization Rating Decision |
When following up on an open-ended hospitalization rating decision
Upon receipt of the reexamination report or cessation of treatment in the day hospital program, assign an applicable schedular evaluation for the residuals.
Notes:
Reference: For more information on award or discontinuance of entitlement to aid and attendance during hospitalization, see M21-1, Part III, Subpart v, 6.C.3.
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Introduction |
This topic contains general information on convalescent ratings under 38 CFR 4.30, including
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Change Date |
December 12, 2018
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IV.ii.2.J.4.a. Convalescent Ratings under 38 CFR 4.30 |
38 CFR 4.30 provides for a temporary 100-percent evaluation without regard to other provisions of the rating schedule if treatment of an SC disability resulted in
Note: The provision allowing assignment of a convalescent rating for outpatient surgery necessitating at least one-month of convalescence became effective March 1, 1989.
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IV.ii.2.J.4.b. Severe Post-operative Residuals for Ratings Under 38 CFR 4.30 |
Under 38 CFR 4.30(a)(2), severe postoperative residuals include but are not limited to
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IV.ii.2.J.4.c. Evidentiary Requirements for Convalescent Ratings |
Entitlement to a temporary total disability rating for convalescence requires that a report rendered near the time of a hospital discharge or an outpatient release indicate that a surgical procedure had been performed that would require at least one month of convalescence for the Veteran to return to a healthy state.
Although a convalescent rating necessitates that surgical intervention must have occurred, there is no requirement that the surgical report be of record when other medical evidence establishes the date of admission, date of discharge, the type of procedure performed, and/or other information relevant to arriving at the convalescence determination.
Reference: For more information on the evidentiary requirements for convalescent ratings, see Felden v. West, 11 Vet. App. 427 (1998).
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IV.ii.2.J.4.d. Work Excuses and Convalescent Ratings |
Entitlement under 38 CFR 4.30 can be established solely by a work excuse from a medical provider if there is
When there is contrary evidence of record, a work excuse will be weighed as one piece of evidence for consideration.
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IV.ii.2.J.4.e. Scope of Convalescence Ratings |
A convalescence rating under the provisions of 38 CFR 4.30 can be prompted based on receipt of a specific claim from a Veteran or based on receipt of a Report of Hospitalization at a VA or uniformed services facility.
Reference: For more information on annotating documents in the claims folder, see the VBMS User Guide.
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IV.ii.2.J.4.f. Convalescence for Disabilities With Common Secondary Etiology |
Assign a convalescence rating for the predominant disability requiring surgical or other treatment necessitating convalescence. When secondary disabilities associated with the primary disability exist, the evaluation for the secondary disabilities will persist during the period of convalescence. Those evaluations may be considered when determining entitlement to SMC.
When evaluating the post-convalescence impairment, consider whether a change in evaluation for the primary and all secondary disabilities is warranted based on the evidence of record.
Example: A Veteran undergoes surgery for an SC neck condition. SC was previously established for bilateral radiculopathy associated with the neck condition. The evidence supports assignment of a convalescence evaluation. Additionally, the additional disabilities—not including the neck but including the radiculopathies—combine for an additional 60-percent evaluation.
Outcome: Assign the convalescence evaluation for the SC neck condition. Continue the evaluations for the radiculopathies. Grant SMC(s) based on statutory housebound status during the period of convalescence. When the convalescence evaluation is reduced, consider whether the pre-convalescence evaluation for the neck and/or radiculopathies warrants adjustment based on the medical evidence.
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IV.ii.2.J.4.g. Determining the Effective Date of Convalescent Ratings |
The temporary total evaluation is assigned effective from the date of hospital admission or outpatient treatment and will continue for a period of one, two, or three months (depending on what the facts support) from the first day of the month following such hospital discharge or outpatient release.
Notes:
Example 1: A Veteran enters the hospital on March 10, 2014, for a total knee replacement and is released on March 13, 2014. The convalescence rating will commence on March 10, 2014. The period of one month convalescence is continued for one month beginning the first day of the month after the date of discharge, which is April 1, 2014, and is followed by the 100-percent rating under38 CFR 4.71a, DC 5055 on May 1, 2014, which will continue for a year.
Example 2: A Veteran enters the hospital on March 30, 2014, for a total knee replacement and is released on April 2, 2014. The convalescence rating will commence on March 30, 2014. The convalescence rating is continued for a one month period beginning on the first day of the month after the date of discharge, which is May 1, 2014. The one month period of convalescence will be followed by the 100-percent rating under 38 CFR 4.71a, DC 5055 on June 1, 2014, which will continue for a year.
Reference: For more information on effective date of convalescence ratings, see38 CFR 3.401(h)(2).
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IV.ii.2.J.4.h. Extension of Convalescent Ratings |
Extensions of temporary total awards are authorized under 38 CFR 4.30(b) when justified by the facts.
A temporary total evaluation awarded for any of the criteria in 38 CFR 4.30(a)(1), (2), or (3) can be extended to a total duration of six months (in incremental amounts of one, two or three months).
Further extensions of one to six months beyond the initial six month period may be made with the following limitations:
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IV.ii.2.J.4.i. Requesting Future Examinations |
Generally, unless required by the diagnostic code, reexamination is not required following a period in which a temporary total rating was assigned under 38 CFR 4.30. The rating activity must review the evidence of record and assign a new post-convalescence evaluation based on the residual disability following the convalescence period.
Only request a VA examination before the end of the total disability period when the evidence is inadequate to determine the residual disability and assign a schedular evaluation after the convalescence period.
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IV.ii.2.J.4.j. Post-Convalescence Evaluations and 38 CFR 3.105(e) |
Assignment of an evaluation lower than 100-percent after the temporary 38 CFR 4.30 convalescence period does not, itself, implicate 38 CFR 3.105(e). The award of a temporary total evaluation with an appropriate schedular evaluation equal to or greater than the pre-convalescence running award rate taking effect thereafter does not create a reduction or discontinuance in compensation payments currently being made. 38 CFR 4.30 states: “The termination of these total ratings will not be subject to §3.105(e) of this chapter.”
Exception: If the residual disability is less disabling than the rating in effect prior to the assignment of temporary total disability under 38 CFR 4.30 so that assigning the appropriate post-convalescence evaluation would result in a reduction or discontinuance in compensation payments made under the running award:
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IV.ii.2.J.4.k. When the Provisions of 38 CFR 4.30 Are Not Applicable |
The use of a convalescent rating is unnecessary if
However, assign the temporary 100-percent convalescent rating under 38 CFR 4.30 from the date of hospital treatment
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Introduction |
This topic contains information on DCs that provide for definite periods of convalescence, including
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Change Date |
July 5, 2015
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IV.ii.2.J.5.a. Temporary Total Evaluations Under a DC for a Definite Period of Convalescence |
The rating schedule prescribes temporary 100-percent evaluations under various DCs for definite periods of time following treatment (including hospitalization), surgery or certain significant disease manifestations.
For the purpose of this section consider these as providing for periods of convalescence regardless of whether or not the word “convalescence” is used or whether the DC refers to 38 CFR 4.30.
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IV.ii.2.J.5.b. DCs Providing for Temporary Total Evaluations – Relationship to 38 CFR 4.29 and 4.30 |
Entitlement to a period of temporary total evaluation under a DC does not necessarily preclude entitlement under 38 CFR 4.29 or 38 CFR 4.30 and vice versa.
Conversely, the fact that a DC provides for a period of temporary total disability does not necessarily mean that disability compensation under 38 CFR 4.29 or 38 CFR 4.30 would be appropriate.
A DC might provide for a temporary total evaluation triggered by hospitalization but not necessarily hospitalization of a sufficient duration to qualify for a 38 CFR 4.29evaluation or hospitalization for surgery or major joint immobilization to qualify for a38 CFR 4.30 evaluation (for example 38 CFR 4.104, DC 7011 provides for a 100-percent evaluation for an indefinite period from the date of hospital admission for initial evaluation and medical therapy for sustained ventricular arrhythmias).
In those cases where a period of convalescence follows another hospitalization, it should begin on the first of the month following
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IV.ii.2.J.5.c. Definition: Definite Periods of Convalescence |
A temporary 100-percent evaluation falls into the category definite periods of convalescence when the DC
Examples:
In both examples the period of total disability and subsequent evaluation can be addressed in the rating decision.
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IV.ii.2.J.5.d. Staged Rating of Definite Periods of Convalescence |
Definite periods of convalescence and subsequent post-convalescence evaluations can be assigned prospectively (where total disability is still ongoing at the time of the rating) or retrospectively (when the period of total disability has already ended). In either case, definite periods of convalescence are assigned as essentially a staged rating.
In the rating assign
When following this rule, 38 CFR 3.105(e) will not apply to the assignment of a disability evaluation less than 100 percent after the total disability period because there will never be a reduction in payments currently being made.
Important: 38 CFR 3.105(e) will apply, however, where a subsequent (further) reduction may be needed that will result in reduction in payments currently being made. This will occur where, for example
Reference: For more information on setting a future examination for a schedular period of convalescence, see M21-1, Part IV, Subpart ii, 2.J.5.i.
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IV.ii.2.J.5.e. Example 1: Staged Rating of Definite Period of Convalescence |
Facts: A prospective increased rating involving a knee replacement under 38 CFR 4.71a, DC 5055. The knee replacement occurred three months before the date of rating. The prior evaluation of the knee was 20 percent. There are no other disabilities.
Result: In the rating decision:
Explanation:
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IV.ii.2.J.5.f. Example 2: Staged Rating of Definite Period of Convalescence |
Facts: A prospective increased rating involving a knee replacement under 38 CFR 4.71a, DC 5055. The knee replacement occurred three months before the date of rating. The prior evaluation of the knee was 50 percent. There are no other disabilities.
Result: In the rating decision
Explanation:
Note: This example is to illustrate staging principles, but in fact patterns like this (a high joint evaluation followed by joint replacement and higher than the minimum evaluation after the temporary total period) strongly consider a future examination to the extent justified by 38 CFR 3.327 and as provided by M21-1, Part IV, Subpart ii, 2.J.5.i.
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IV.ii.2.J.5.g. Example 3: Staged Rating of Definite Period of Convalescence |
Facts: A retrospective increased rating involving a knee replacement under 38 CFR 4.71a, DC 5055. The claim was received 11 months after the knee replacement. A Disability Benefits Questionnaire showed that the prosthetic was stable and the Veteran was asymptomatic. The prior, running evaluation of the knee was 40 percent. There are no other disabilities.
Result: In the rating decision
Explanation:
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IV.ii.2.J.5.h. Control and Assignment of Definite Convalescence Period |
A definite convalescence period requires no future control. If rated correctly there is no potential for overpayment of the total disability period. The rating that assigns the 100-percent evaluation also sets a subsequent evaluation to take effect after the specified period of total disability ends.
Reference: For information about control of indefinite periods of convalescence, see M21-1, Part IV, Subpart ii, 2.J.6.
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IV.ii.2.J.5.i. Reexamination After a Definite Period of Convalescence |
When preparing a rating decision prospectively awarding a definite period of convalescence and a subsequent evaluation as provided in M21-1, Part IV, Subpart ii, 2.J.5.d, do not schedule a future examination before the end of the temporary total period.
However, a future examination date may be entered in VBMS-R to ensure that the disability will be reexamined and reevaluated after the prescribed convalescence period has expired. These exams may be necessary to determine
Generally, when retrospectively awarding a period of temporary total disability, the level of disability after the end of the period of total disability (the current level of disability) will be known. In such cases do not establish a future examination control except as provided in 38 CFR 3.327(b) and M21-1, Part III, Subpart iv, 3.B.2.
Reference: For more information on scheduling review examinations, see M21-1, Part III, Subpart iv, 3.B.2.
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6. DCs That Provide for Indefinite Periods of Convalescence
Introduction |
This topic contains information on DCs that provide for indefinite periods of convalescence, including
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Change Date |
July 5, 2015
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IV.ii.2.J.6.a. Indefinite Periods of Convalescence Under a DC |
The rating schedule prescribes temporary 100-percent evaluations under various DCs for indefinite periods of time following treatment (including hospitalization), surgery or certain significant disease manifestations.
For the purpose of this section consider these as providing for periods of convalescence regardless of whether or not the word “convalescence” is used or whether the DC refers to 38 CFR 4.30.
Reference: For more information about the interrelationship between convalescence under a DC generally and 38 CFR 4.29 or 38 CFR 4.30 see M21-1, Part IV, Subpart ii, 2.J.5.b.
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IV.ii.2.J.6.b. Definition: Indefinite Periods of Convalescence |
A temporary 100-percent evaluation falls into the category indefinite periods of convalescence when
Key features of DC provisions providing for indefinite periods of convalescence also include
Examples:
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IV.ii.2.J.6.c. Prospective Ratings Under Indefinite Periods of Convalescence and 38 CFR 3.105(e) |
38 CFR 3.105(e) applies to reductions from the period of total disability specified in DCs providing for indefinite periods of convalescence because these evaluations are most often awarded prospectively (total disability is still ongoing at the time of the rating).
At time of rating the decision maker will not know either one of the following:
Therefore, the 100-percent evaluation is assigned as an open or running evaluation and later assignment of a lower evaluation after the indefinite period of convalescence can result in a reduction or discontinuance of compensation payments being made.
When preparing a rating decision prospectively establishing a temporary total evaluation for an indefinite period of convalescence
Later, when the period of total disability has ended, before assigning a lower evaluation
References: For more information on
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IV.ii.2.J.6.d. Retrospective Evaluations of Indefinite Periods of Convalescence and 38 CFR 3.105(e) |
It is possible, in rare cases that a temporary total evaluation under an indefinite period of convalescence can be assigned retrospectively (when the period of total disability has already ended).
This can occur when a claim has a long duration or where the period of total disability was short.
In such cases the period of total disability and the subsequent disability level will be actually known at the time of rating. Staging up to 100 percent and then down to the appropriate following level will not require application of the provisions of 38 CFR 3.105(e) as long as there is not a reduction in compensation payments currently being made.
Important: If the total evaluation is reduced as part of a staged rating in the award for the original claim for such disability, then the provisions of 38 CFR 3.105(e) do not apply.
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IV.ii.2.J.6.e. Cancer Evaluations |
Almost all cancers are evaluated using the same analysis. See the table below for a description.
Reference: For more information on scheduling review examinations, see M21-1, Part III, Subpart iv, 3.B and C.
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IV.ii.2.J.6.f. Example– Staged Cancer Evaluation |
Facts:
Result:
Explanation:
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Historical_M21-1IV_ii_2_SecJ_7-21-15.docx | May 21, 2019 | 101 KB |
12-12-18_Key-Changes_M21-1IV_ii_2_SecJ.docx | May 21, 2019 | 73 KB |
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2-21-18_Key-Changes_M21-1IV_ii_2_SecJ.docx | May 21, 2019 | 93 KB |
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in Chapter 2 Rating, Part IV Compensation, DIC, and Death Compensation Benefits, Subpart ii Compensation
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