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M21-1, Part VI, Chapter 2, Section C – Rating

Overview


In This Section

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

1.  Rating Process Overview for Chapter 18 Benefits


Introduction

This topic contains information on the rating process, including


Change Date

December 12, 2018

VI.2.C.1.a.  Decision-Making Roles and Responsibilities

The roles and responsibilities for making a decision in Chapter 18 benefit claims are shown in the following table.
If all elements of basic eligibility …
Then the …
are not met
authorization activity decides the claim.
Note:  No referral to the rating activity is needed.
References:  For more information on
are met
rating activity
  • considers the medical and lay evidence, and
  • determines whether to award or deny entitlement to a monthly monetary allowance.
Note:  All Chapter 18 claims fall under the jurisdiction of the Denver Regional Office, per M21-1, Part VI, 1.1.

VI.2.C.1.b.  Rating a Claim Based on Spina Bifida

The table below provides guidance for the rating activity to follow when making a decision on a spina bifida claim.
If the claimed disability is …
Then …
  • diagnosed as spina bifida occulta, or
  • diagnosed as other than spina bifida
prepare a rating decision denying the claim.
spina bifida
  • prepare a rating decision establishing entitlement, as
    • Level I
    • Level II, or
    • Level III, and
  • determine a beginning date of entitlement as provided in 38 CFR 3.814(e).

VI.2.C.1.c.  Rating a Claim Based on Other Covered Birth Defects

The table below provides guidance for the rating activity to follow when making a decision on other covered birth defect claims.
If the claimed disability is …
Then …
not a covered birth defect, per 38 CFR 3.815 (c)(3) and (d)
prepare a rating decision denying the claim.
a covered birth defect per 38 CFR 3.815 (c)(3) and (d)
  • prepare a rating decision establishing entitlement, as
    • Level I
    • Level II
    • Level III,
    • Level IV, or
    • Level 0, if the individual has no current disability resulting from a covered birth defect,and
  • determine a beginning date of entitlement as provided in 38 CFR 3.815(i).

VI.2.C.1.d.  Assigning Effective Dates Under 38 CFR 3.814(e) and (f)

The effective date for a grant of a monetary allowance based on spina bifida(whether based on an initial or supplemental claim) will generally be the later of the following dates:

  • the date the Department of Veterans Affairs (VA) received the claim
  • the date of birth if the claim is received within one year of that date, or
  • the date entitlement arose.

Exceptions:

  • An increase will be effective the earliest date the evidence establishes that the level of severity increased, but only if the beneficiary applies for an increase within one year of that date.
  • If granting a supplemental claim based on corrected military records, VA will award the benefit from the latest of the following dates:
    • the date the Veteran or beneficiary applied for a correction of the military records
    • the date the previously disallowed claim was filed, or
    • the date one year before the date of receipt of the supplemental claim.

Important:  The effective date cannot be earlier than October 1, 1997.

Reference:  For more information about the effective date of awards and commencement of payments of monetary allowances for spina bifida, seeVAOPGCPREC 3-1999.


VI.2.C.1.e.Assigning Effective Dates Under 38 CFR 3.815(i) and (j)

The effective date for a grant of a monetary allowance based on other covered birth defects (whether an initial or supplemental claim) will generally be the latest of the following dates:

  • the date VA received the claim
  • the date of birth if the claim is received within one year of that date, or
  • the date entitlement arose

Exceptions:

  • Apply 38 CFR 3.114(a) as applicable.
  • An increase will be effective the earliest date the evidence establishes that the level of severity increased, but only if the beneficiary applies for an increase within one year of that date.
  • If granting a supplemental claim based on corrected military records, VA will award the benefit from the latest of the following dates:
    • the date the Veteran or beneficiary applied for a correction of the military records
    • the date the previously disallowed claim was filed, or
    • the date one year before the date of receipt of the supplemental claim.

Important:  No benefits may be paid for any period prior to December 1, 2001.


VI.2.C.1.f. Reductions and Discontinuances

Reductions and discontinuances must be made as provided in 38 CFR 3.814(f) or38 CFR 3.815(j).
VA will generally reduce or discontinue awards according to the facts found except as provided in 38 CFR 3.105 and 38 CFR 3.114(b).
  • If benefits were paid erroneously because of beneficiary error, VA will reduce or discontinue benefits as of the effective date of the erroneous award.
  • If benefits were paid erroneously because of administrative error, VA will reduce or discontinue benefits effective the date in the LAST PAID DATE field on the AWARD INFORMATION tab in Share.

2.  Disability Rating Levels Assigned to Spina Bifida Claims


Introduction

This topic contains information on


Change Date

December 12, 2018

VI.2.C.2.a.  Spina Bifida Disability Levels

Once the rating activity determines that the individual is entitled to benefits based on spina bifida disability, it assigns the highest disability level based on severity of symptoms and degree of any permanent physical or mental disability.
The table below describes the disability levels for spina bifida ratings.
Level
Description
I
The individual
  • walks without braces or other external support as his/her primary means of mobility in the community
  • has no sensory or motor impairment of upper extremities
  • has an IQ of 90 or higher, and
  • is continent of urine and feces without the use of medicationor other means to control incontinence.
II
The individual meets any of the criteria listed below. He/she
  • walks with braces or other external support as his/her primary means of mobility in the community
  • has sensory or motor impairment of upper extremities, but is able to
    • grasp a pen
    • feed self, and
    • perform self-care
  • has an IQ of at least 70 but less than 90
  • requires medication or other means to control the effects of urinary bladder impairment and no more than two times per week is unable to remain dry for at least three hours at a time during waking hours
  • requires bowel management techniques or other treatment to control the effects of bowel impairment but does not have fecal leakage severe or frequent enough to require wearing absorbent materials at least four days a week, or
  • has colostomy that does not require wearing a bag.
Note:  The rating activity assigns a disability at Level II provided that none of the disabilities is severe enough to warrant payment at Level III.
III
The individual meets any of the criteria listed below. He/She
  • uses a wheelchair as his/her primary means of mobility in the community
  • has sensory or motor impairment of the upper extremities severe enough to prevent
    • grasping a pen
    • feeding self, and
    • performing self-care
  • has an IQ of 69 or less
  • at least three times a week is unable to remain dry for three hours at a time during waking hours, despite the use of medication or other means to control the effects of urinary bladder impairment
  • has fecal leakage severe or frequent enough to require wearing of absorbent materials at least four days a week, despite bowel management techniques or other treatment to control the effects of impairment
  • regularly requires manual evacuation or digital stimulation to empty the bowel, or
  • has a colostomy that requires wearing a bag.

VI.2.C.2.b.  Categories of Neurological Impairment

In determining the appropriate disability level to assign, the rating activity assesses the severity of each category of neurological impairment (extremities functioning, mental functioning, and bowel-bladder functioning) as

  • least severe (1)
  • intermediate severity (2), or
  • most severe (3).
The rating activity records these category values on the Codesheet.
Important:  The highest level assigned for any of the categories determines the overall level of disability.
Example:  If extremities and bowel-bladder functions are not impaired (each scored 1) but IQ is 80 (scored as 2), then disability Level II is assigned.

VI.2.C.2.c.  Minimum Disability Level Assignable

The rating activity assigns the highest evaluation warranted by the evidence of record.  The minimum disability level assignable is Level I.
Assign a Level I
  • if basic entitlement is granted, but there is no or insufficient evidence to determine the disability level, and
  • until one of the following is received supporting a higher level:
    • additional medical evidence, or
    • VA examination report.

The rating activity prepares a deferred rating under code 38 while the required evidence is pending.  The minimum disability Level I remains in effect even if the individual fails to report for a VA examination.


VI.2.C.2.d.  Disability Level for Children Under the Age of One Year

The rating activity assigns disability Level I for children under the age of one year unless a pediatric neurologist or pediatric neurosurgeon certifies that, in his or her medical judgment, there is neurological deficit that will prevent the child from

  • ambulating
  • grasping a pen
  • self-feeding
  • performing self-care, or
  • achieving urinary or fecal continence.

If such a deficit is present, the rating activity assigns disability Level III.


VI.2.C.2.e.  Exceptional Cases

The Director of Compensation Service may increase the monthly allowance in order to best represent the extent that the disabilities resulting from spina bifida, or from treatment procedures for spina bifida, limit the individual’s ability to engage in ordinary, day-to-day activities.
The Director may increase the monthly payment for an individual who would otherwise be paid at Level I or II, if there are one or more disabilities resulting from spina bifida, or treatment for spina bifida, such as
  • blindness
  • uncontrolled seizures, or
  • renal failure.

In this case, the individual may receive a Level II or Level III payment, depending on whether the effects of a disability are equal in severity to the effects specified under Level II or III.


VI.2.C.2.f.  Scheduling Periodic Reassessments of Disability Level

VA will periodically reassess the disability level of a beneficiary.
Use the table below to determine the course of action for scheduling the periodic reassessments of the disability level.
When the individual is …
Schedule a reassessment …
under the age of one
when the individual is one year old.
between the age of one and twenty-one
when medical evidence is received indicating a change is warranted, but at a minimum every five years.
over the age of twenty-one
only if evidence indicates
  • a material change in disability, or
  • the current rating may be incorrect.

 

3.  Disability Rating Levels Assigned to Other Covered Birth Defect Claims


Introduction

This topic contains information on


Change Date

December 12, 2018

VI.2.C.3.a.  Other Covered Birth Defects Disability Levels

In the process of examining medical evidence, the rating activity determines a disability level for each case qualifying for other covered birth defect benefits.
The table below describes the disability levels for other covered birth defect ratings.
Level
Description
0
The individual has no current disability resulting from covered birth defects.
I
The individual
  • has residual physical or mental effects that only occasionallyor intermittently limit or prevent some daily activities, or
  • has disfigurement or scarring of the head, face, or neck with gross distortion or gross asymmetry of any facial feature (nose, chin, forehead, eyes (eyelids), ears (auricles), cheeks, or lips).
II
The individual has residual physical or mental effects that frequently or constantly limit or prevent some daily activities, but the individual
  • is able to work or attend school
  • can carry out most household chores
  • can travel
  • provides age-appropriate self-care, and
  • displays communication, behavior, social interaction, and intellectual functioning appropriate for age, or
  • has disfigurement or scarring of the head, face, or neck with either gross distortion or gross asymmetry of one facial feature or one paired set of facial features (nose, chin, forehead, eyes (eyelids), ears (auricles), cheeks, or lips).
III
The individual
  • has residual physical or mental effects that limit or hinder most daily activities, but the individual is able to provide age-appropriate self-care, such as
    • eating
    • dressing
    • grooming, and
    • carrying out personal hygiene
  • may be unable, or does so intermittently and with difficulty, to
    • attend school
    • travel, or
    • carry out household chores
  • displays communication, behavior, social interaction, and intellectual functioning that are not entirely appropriate for age, or
  • has disfigurement or scarring of the head, face, or neck with either gross distortion or gross asymmetry of two facial features or two paired sets of facial features (nose, chin, forehead, eyes (eyelids), ears (auricles), cheeks, or lips).
IV
The individual
  • has residual physical or mental effects that prevent age-appropriate self-care, such as
    • eating
    • dressing
    • grooming, and
    • carrying out personal hygiene
  • displays communication, behavior, social interaction, and intellectual functioning that are grossly inappropriate for age,or
  • has disfigurement or scarring of the head, face, or neck with either gross distortion or gross asymmetry of three facial features or three paired sets of facial features (nose, chin, forehead, eyes (eyelids), ears (auricles), cheeks, or lips).
Reference:  For more information on other covered birth defects, see

VI.2.C.3.b.  Exceptional Cases

The Director of Compensation Service may increase the monthly allowance in order to best represent the extent that the disabilities resulting from other covered birth defects, or from treatment procedures for covered birth defects, limit the individual’s ability to engage in ordinary, day-to-day activities.
The Director may increase the monthly payment for an individual who would otherwise be paid at Level I , II, or III, if there are one or more disabilities resulting from other birth defects, or treatment for other birth defects, such as
  • blindness
  • uncontrolled seizures, or
  • renal failure.
In this case, the individual may receive a Level II, III, or IV payment, depending on whether the effects of a disability are equal in severity to the effects specified under Level II, III, or IV.

VI.2.C.3.c.  Scheduling Periodic Reassessments of Disability Level

VA will reassess a determination whenever it receives evidence indicating that a change is warranted.

4.  Preparation of a Chapter 18 Benefits Rating Decision


Introduction

This topic contains information on preparing a rating decision, specifically the ratingCodesheet, including entries on the Codesheet for


Change Date

April 29, 2015

VI.2.C.4.a.  Entries on the Codesheet for Spina Bifida Claims

Whether granted or denied, all rating decisions require certain entries on theCodesheet.

Use the table below to determine how to annotate the Codesheet.

If benefits are …
Then state the coded conclusion as …
Example
granted
Spina bifida benefits followed by
  • disability level (I, II, or III)
  • a parenthetical evaluation for each of the three categories of neurological impairment (1, 2, or 3), and
  • the effective date.
Notes:
  • When a minimum evaluation is assigned because of insufficient medical evidence, indicate minimum as the parenthetical evaluation as follows:Level I (minimum) from 10-01-01.
  • If additional development is conducted for medical evidence, reflect the deferred rating as a code 38 on theCodesheet.
Spina bifida benefits Level II (extrm 1, control 1, intel 2) from 10-01-01
denied
Spina bifida benefits deniedfollowed on the next line by
  • 02-Diagnosis of spina bifida occulta, or
  • 03-No spina bifida condition.
Spina bifida benefits denied
02-Diagnosis of spina bifida occulta
Note:  A  rating decision is not prepared for claims that have been denied for the following reasons:
  • the child was conceived before the specific Korean or Vietnam service
  • the claimant failed to furnish requested evidence
  • the parent(s) were not Vietnam Veteran(s) or Veterans with specific Korean service, or
  • the individual is not a natural child of the Veteran.
References:  For more information on

VI.2.C.4.b.  Entries on Codesheet for Other Covered Birth Defect Claims

Whether granted or denied, all rating decisions require certain entries on theCodesheet.  Follow the instructions below to determine how to annotate theCodesheet.

Granted
State:  Chapter 18 benefits are granted for [insert name of defect] at Level [insert Level 0, I, II, III or IV] effective [insert date].
If benefits are granted at Level 0, state:  No current disability exists, entitlement for treatment purposes and vocational training only.
Example 1:  Chapter 18 benefits are granted for cleft lip at Level I effective 12-01-2001.
Example 2:  Chapter 18 benefits are granted for Poland syndrome at Level II effective 01-01-2002.
Denials
State:  Chapter 18 benefits are denied for [insert name of claimed condition].  Then, list the reason:
  • no qualifying birth defect exists
  • disability due to familial disorder
  • disability resulted from birth-related injury
  • disability is the result of a fetal or neo-natal infirmity with well-established causes
  • disability not a permanent physical or mental disability
  • disability due to congenital malignant neoplasm
  • disability due to chromosomal disorder, or
  • disability due to developmental disorder.
Note:  A rating decision is not prepared for claims that have been denied for the following reasons:
  • the individual was conceived before the Veteran-parent first served in the Republic of Vietnam during the Vietnam era, per M21-1, Part VI, 2.B.3
  • the individual failed to furnish requested evidence
  • the biological mother was not a Vietnam Veteran
  • Veteran-parent is not female
  • child deceased prior to 12-01-2001, or
  • the individual is not a natural child of the Veteran.
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