Department of Defense

INSTRUCTION

NUMBER 1332.39

November 14, 1996

ASD(FMP)

SUBJECT:  Application of the Veterans Administration
Schedule for Rating Disabilities 

References:  (a)  DoD Directive 1332.18, “Separation
or Retirement for Physical Disability”, November 4,
1996

(b)  Title 10, United States Code

(c)  DoD Instruction 1332.38, “Physical Disability Evaluation”,
November 14, 1996

(d)  Veterans Administration Schedule for Rating Disabilities
(38 CFR, Part 4)

(e)  DoD Directive 6130.3, "Physical Standards for Appointment,
Enlistment, and Induction," May 2, 1994

(f)  Title 37, United States Code

1.  PURPOSE 

This Instruction implements policy, assigns responsibilities,
and prescribes procedures, under the authority of reference
(a), for rating disabilities of Service members determined
to be physically unfit and who are eligible for disability
separation or retirement under reference (b).

2.  APPLICABILITY 

This Instruction applies to the Office the Secretary
of Defense (OSD) and the Military Departments.

3.  DEFINITIONS 

Terms used in this Instruction are defined in enclosure
1.

4.  POLICY 

4.1.  Ratable Disabilities.    Disabilities determined
to be physically unfitting and compensable under reference
(c) shall be assigned a percentage rating.

4.2.  Standard.    Chapter 61 of reference (b) establishes
the Department of Veterans Affairs’(DVA) Veterans Administration
Schedule for Rating Disabilities (VASRD) (reference
(d)) as the standard for assigning percentage ratings.
  The percentage ratings represent, as far as can practicably
be determined, the average impairment in civilian occupational
earning capacity resulting from certain diseases and
injuries, and their residual conditions.   However,
not all the general policy provisions in Sections 4.1
- 4.31 of the VASRD are applicable to the Military Departments.
  Many of these policies were written primarily for
DVA rating boards, and are intended to provide guidance
under laws and policies applicable only to the DVA.
  This Instruction replaces these sections of the VASRD.
  The remainder of the VASRD is applicable except those
portions that pertain to DVA determinations of Service
connection, refer to internal DVA procedures or practices,
or are otherwise specifically identified in Enclosure
2 as being inapplicable.

5.  RESPONSIBILITIES 

5.1.  The Assistant Secretary of Defense for Force Management
Policy, under the Under Secretary of Defense for Personnel
and Readiness, shall ensure consistency between this
Instruction and DoD Directive 1332.18 (reference (a))
and DoD Instruction 1332.18 (reference (c)).

5.2.  The Assistant Secretary of Defense for Health
Affairs, under the Under Secretary of Defense for Personnel
and Readiness, shall:

5.2.1.  Perform, on a periodic basis, such review as
is necessary to determine uniform application by the
Military Departments of the VASRD as modified by this
Instruction.

5.2.2.  Amend or modify this Instruction, as appropriate,
after coordination of any proposed amendment or modification
with the Assistant Secretary of Defense for Force Management
Policy and the Secretaries of the Military Departments.

5.2.3.  Review substantive changes proposed by the Military
Departments for rating disabilities which affect the
uniformity of ratings provided for in this Instruction.

5.3.  The Secretaries of the Military Departments shall
ensure their respective physical disability evaluation
systems apply the VASRD in accordance with this Instruction.

6.  PROCEDURES 

6.1.  Essentials of Rating Disabilities 

6.1.1.  The VASRD.    The VASRD is primarily used as
a guide for evaluating disabilities resulting from all
types of diseases and injuries encountered as a result
of, or incident to, Military Service.   Because of differences
between Military Department and DVA applications of
rating policies for specific cases, differences in ratings
may result.   Unlike the DVA, the Military Departments
must first determine whether a Service member is fit
to reasonably perform the duties of the member’s office,
grade, rank, or rating.   Once a Service member is determined
to be physically unfit for further Military Service,
VASRD percentage ratings are applied to the unfitting
condition(s).   Percentages are based on the severity
of the condition(s).

6.1.2.  Medical Treatment at the Time of Voluntary and/or
Mandatory Separation and/or Retirement.    Medical and
surgical procedures are frequently performed near the
end of a Service member's military career.   Those are
intended to improve a Service member's health.   Corrective
treatment and convalescence will not be considered as
a valid contribution to disability unless unexpected
adverse effects occur that are expected to persist after
discharge from active duty and are ratable.

6.1.3.  Failure to Comply with Prescribed Treatment.
   A Service member’s degree of disability may have
been aggravated or increased by an unreasonable failure
or refusal to submit to medical or surgical treatment
or therapy, to take prescribed medications, or to observe
prescribed restrictions on diet, activities, or the
use of alcohol, drugs or tobacco.   The compensable
disability rating may be reduced to compensate for such
aggravation when the existence and degree of aggravation
are ascertainable by application of accepted medical
principles, and where it is clearly demonstrated that:

6.1.3.1.  The Service member was advised clearly and
understandably of the medically proper course of treatment,
therapy, medication or restriction; and

6.1.3.2.  The Service member’s failure or refusal was
willful or negligent, and not the result of mental disease
or of physical inability to comply.

6.1.4.  Illegal and/or Controlled Substances.    The
following applies to Unfitting Medical Disorders and/or
Conditions that result from the use of Substance Abuse
and/or Chemical Dependency:

6.1.4.1.  Illegal and/or Controlled Substances or generally
known toxins; e.g., cocaine, PCP, LSD, & heroin:   Treat
as misconduct unless use was the product of an otherwise
unfitting condition.

6.1.4.2.  Other substances, e.g., alcohol and Nicotine:
  Any physical disability resulting from post Level
II or III or equivalent treatment will be considered
as Non-Compliance.

6.1.5.  Objective Medical Findings and Disability Ratings.
   Physical examination findings, laboratory tests,
radiographs and other findings are not, in themselves,
ratable.   A rating for a disability must be based on
demonstrable impairment of function unless otherwise
provided in this regulation.

6.1.6.  Elective Surgery or Treatment.    Prior to any
elective treatment by the Military Health Services System
(MHSS), a Service member must consult with a competent
military medical authority.   A Service member who elects
to have such treatment done at his or her own expense
will not be eligible for compensation under the provisions
of this Instruction for any adverse residuals resulting
from the elected treatment, unless it can be shown that
such election was reasonable or resulted from a significant
impairment of judgment that is the product of a ratable
medical condition.   A record of the counseling will
be made by the Health Benefits Advisor or other designated
individual to document that the member was counseled
about the elective treatment and his or her subsequent
ineligibility for disability compensation for any adverse
residuals incurred secondary to the elective treatment.

6.1.7.  Disabilities Not Unfitting for Military Service.
   Conditions that do not themselves render a Service
member unfit for military service will not be considered
for determining the compensable disability rating unless
they contribute to the finding of unfitness.

6.1.8.  The Relative Contribution of Non-Compensable
Medical Conditions (Condition(s) Not Considered Physical
Disabilities) to Current Industrial Impairment of Ratable
Neuropsychiatric Conditions.    Personality Disorder(s),
Impulse Control Disorders, or Substance Use and/or Abuse
Disorder(s) are examples of condition(s) not constituting
a physical disability that often significantly contribute
to, or may be the chief cause of, any industrial and
industrially related social impairment suffered by the
Service member who has a compensable Neuropsychiatric
condition.   Unfitting disability resulting therefrom
will not be rated.   In such instances, the overall
rating of psychiatric impairment will be reduced to
the impairment rating that would be warranted in the
absence of the influence of the non-compensable condition
according to generally accepted medical principles.
  It is imperative that the Medical Evaluation Board
(MEB) quantify the contribution of each medical condition
to the overall industrial impairment manifested by the
Service member.

6.2.  Higher of Two Evaluations.    When the circumstances
of a case are such that two percentage evaluations could
be applied, the higher percentage will be assigned only
if the Service member's disability more nearly approximates
the criteria for that rating.   Otherwise, the lower
rating will be assigned.   When, after careful consideration
of all reasonably procurable and assembled data, there
remains a reasonable doubt as to which rating should
be applied, such doubt will be resolved in favor to
the member.

6.3.  Changes in Rating Criteria.    Members on the
TDRL shall be rated under the VASRD criteria in effect
at the time of their final reevaluation.

6.4.  Pyramiding.    Pyramiding is the term used to
describe the application of more than one rating to
any area or system of the body when the total functional
impairment of that area or system is adequately reflected
under a single appropriate code.   Disability from injuries
to the muscles, nerves, and joints of the extremity
may overlap to a great extent.   Special rules for their
valuation are included in appropriate sections of the
VASRD and in enclosure 2 of this Instruction.   Related
diagnoses should be merged for rating purposes when
the VASRD provides a single code covering all their
manifestations.   This prevents pyramiding and reduces
the chance of over-rating.   For example, disability
from fracture of a tibia involving malunion, limitations
of dorsiflexion, eversion, inversion, and subtalar motion,
as well as traumatic arthritis of the ankle would be
rated using one diagnostic code (5271) that reflects
overall ankle function, rather than by adding separate
ratings for the limitations of motion and the traumatic
arthritis.

6.5.  Total Disability Rating.    Total disability will
be considered to exist when the member's impairment
is sufficient to render it impossible for the average
person suffering the same medical condition to engage
in a substantially gainful civilian occupation.   Accordingly,
in cases in which the VASRD does not provide a 100 percent
rating under the appropriate (or analogous) code, a
member may be assigned a disability rating of 100 percent
if the member's impairment is sufficient to render it
impossible to engage a substantially gainful occupation.

6.6.  Extra-Schedule Ratings in Exceptional Cases. 
  The requirement to use the VASRD in rating disabilities
does not prevent the Secretary of the Military Department
concerned from assigning ratings in unusual cases not
covered by the VASRD.   In such cases, extra-schedule
ratings commensurate with the average earning capacity
impairment due exclusively to Service-connected disability
may be assigned.   Such cases must be rated in accordance
with procedures established by the Secretary of the
Military Department concerned.   The basis of the conclusion
that the case presents such an exceptional or unusual
disability picture that the regular VASRD standards
do not apply must be documented.

6.7.  Convalescent Ratings.    Under certain diagnostic
codes, the VASRD provides for a convalescent rating
to be awarded for specified periods of time without
regard to the actual degree of impairment of function.
  SUCH RATINGS DO NOT APPLY TO THE MILITARY DEPARTMENTS.
  Convalescence will ordinarily have been completed
by the time optimum hospital improvement (for disposition
purposes) has been attained.   If not, rate according
to the manifest impairment.

6.8.  Observation Ratings.    The VASRD, in cases of
malignancy, has ratings applicable for a one to two
year period of observation.   Following this period
of observation residuals will be rated. Observation
ratings do apply to the Military Departments.

6.9.  Analogous Ratings.    When an unlisted condition
is encountered, it is permissible to rate it by analogy
to a closely related disease or injury.   The unlisted
and analogous conditions should reflect adverse impact
upon reasonably similar functions, anatomical structures,
or be symptomatically similar.   Conjectural analogies,
analogous ratings for conditions of doubtful diagnosis,
and diagnoses not fully supported by clinical/laboratory
findings are not acceptable.   Organic diseases or injuries
will not be rated by analogy to disorders of psychiatric
origin (VASRD codes 9000 - 9511), except when directed
by law (e.g., Gulf War cases).   (See the Analogous
Rating Table, enclosure 3).

6.10.  Zero Percent Ratings and Minimum Ratings 

6.10.1.  Occasionally, a medical condition that causes
or contributes to unfitness for military service is
of such mild degree that it does not meet the criteria
for even the lowest rating provided in the VASRD under
the applicable code.   A zero percent rating may be
applied in such cases even though the lowest rating
listed is 10 percent or more, except when "minimum ratings"
are specified.   The "Bilateral Factor" (see paragraph
6.13.) will be applied when a disability is present
in two paired extremities, even though one extremity
is rated at zero percent.

6.10.2.  In some instances, the VASRD provides a "minimum
rating,” without qualifications as to residuals or impairment.
  Diagnosis alone is sufficient to justify the minimum
rating. Syringomyelia, code 8024, is an example.   Although
higher ratings may be awarded in consonance with degree
of severity, no rating lower than the "minimum" may
be used if the diagnosis is satisfactorily established.

6.10.3.  The VASRD provides a minimum rating for "residuals"
in certain medical conditions.   A given Instruction
may state, "rate residuals, minimum _______ percent,"
or may specify what impairment to rate and give a minimum
rating for that impairment.   Examples are code 8011,
anterior poliomyelitis, and 6015, benign new growth
of eyeball and adnexa, other than superficial.   To
justify the minimum rating for residuals, a functional
impairment or other residual caused by the condition
must exist.   Otherwise, a zero percent is appropriate
if the primary condition is unfitting.

6.11.  Rating of Medical Impairments Existing Prior
To Service 

6.11.1.  Permanent Service Aggravation.    A medical
condition manifesting itself prior to entry into military
service will be considered "permanently service aggravated"
when military service lastingly worsens that medical
condition beyond its natural progression.   Generally
accepted medical principles will be used to determine
"natural progression".

6.11.2.  No Permanent Aggravation.    For service members
for whom no permanent service aggravation has occurred,
no rating will be listed.   However, the rationale will
state the basis for the determination that the unfitting
condition existed prior to service (EPTS) and was not
permanently aggravated by service.   When the condition
is considered unfitting due to natural progression without
permanent service aggravation, the accepted medical
principle that supports the finding of "natural progression"
will be addressed in all cases for which a rationale
for the findings is published.

6.11.3.  Aggravation and Present Degree of Disability
Less than 100 percent.    In cases involving service
members with permanent service aggravation and a current
degree of impairment less than total, the rating will
reflect only the degree of disability over and above
that existing at the time of entrance into active service.
  This requirement applies whether the particular condition
was noted at the time of entrance into active service
or is later determined, upon the evidence of record,
to have existed at that time.   It is necessary, therefore,
to deduct from the present degree of disability the
degree of disability, if ascertainable, that existed
prior to entrance into active service.   In assessing
EPTS disability, the full EPTS clinical course of the
impairing medical condition will be taken into consideration.
  Such deduction should be in terms of the rating schedule
for the given condition.   The deduction will be recorded
on the rating sheet.   If the degree of disability at
the time of entrance into the Military Service is not
ascertainable in terms of the schedule, no deduction
will be made.   The rating sheet will reflect that the
EPTS factor is indeterminable, and a zero percent deduction
will be made.

6.11.4.  Aggravation and Present Degree of Disability
100 percent.    When permanent service aggravation has
occurred and the current degree of disability is 100
percent, the rating sheet will reflect the EPTS factor,
but no deduction will be made.

6.11.5.  Congenital and Hereditary Conditions.    Congenital
and hereditary conditions that do not manifest symptomatology
until after a member enters active duty under orders
specifying a period of more than 30 days shall not be
considered Service-incurred.   These conditions will
be presumed service aggravated unless a preponderance
of evidence based on accepted medical principles clearly
establishes that the condition is solely the time result
of the natural progression of the congenital or hereditary
condition.

6.11.6.  Paired Organs Involving EPTS and Service Aggravation.
   No deduction for EPTS factor will be made when the
member is unfit for any of the following situations
involving paired organs.   However, the rating sheet
will reflect the EPTS factor, and that the EPTS deduction
is zero (0) percent.

6.11.6.1.  Blindness in one eye as a result of Service-connected
disability and blindness in the other eye as a result
of non-service connected disability.

6.11.6.2.  Loss or loss of use of one kidney as a result
of Service-connected disability and involvement of the
other kidney as a result of non-service connected disability.

6.11.6.3.  Total deafness in one ear as result of Service-connected
disability and total deafness in the other ear as a
result of non-service connected disability.

6.11.6.4.  Permanent Service-connected disability of
one lung, rated 50 percent or more disabling, in combination
with a non-service connected disability of the other
lung.

6.12.  Combined Ratings Table.    When a member has
more than one compensable disability, the percentages
are combined rather than added (except when the VASRD
modified by enclosure 2 indicates otherwise).   The
combined rating is based on the "whole person concept".
  A person without a medical impairment is considered
100% fit.   An unfitting ratable medical impairment
renders an individual less that 100% fit.   A revised
fitness level results.   Subsequent impairments are
calculated as a percentage basis of the new fitness
level that is always less than 100%.   Thus, a person
having a 60 percent disability is considered to have
a remaining efficiency or fitness of 40 percent.   If
there is a second disability rated at 20 percent, then
the person is considered to have lost 20 percent of
that remaining 40 percent, (20% x 40% = 8%).   Hence,
a 60 percent disability combined with a 20 percent disability
results in a combined rating of 68 percent, and a 70%
rating in the VASRD.   The combined rating for any combination
of disabilities is always determined by first arranging
the disabilities in their exact order of severity and
then referring to the Combined Ratings Table in the
VASRD in accordance with the following Instructions:

6.12.1.  Combining Two Percentages.    The higher impairment
percentage is located in the left-hand column.   The
combined percentage is found where the row indicating
the percentage of the first (higher) impairment intersects
with the column headed by the percentage of the second
impairment.

6.12.2.  Combining Three or More Percentages.    The
first two percentages are combined as indicated in subparagraph
6.12.1., above.   The result is a new impairment percentage
that can be combined with a third percentage following
the same procedure as in subparagraph 6.12.1., above.
  (Example: 50 combined with 30 equals 65.   65 combined
with 20 equals 72).   If there are additional percentages,
the procedure is repeated using the new combined value
and the next percentage.   Rounding off is not done
until the final value has been calculated and converted
as described below in paragraph 6.12.3.

6.12.3.  Converting a Combined Rating.    After all
percentages have been combined, the resulting combined
value is converted to the nearest number divisible by
10.   Combined values ending in 5 are adjusted upward.
  If the combined value includes a decimal fraction
of 0.5 or more as a result of applying the bilateral
factor (see paragraph 6.13.), the fraction is converted
to the next higher whole number; otherwise the decimal
fraction is disregarded.   (Example:   If the combined
value is 64.5, the fraction is rounded to a combined
value of 65, which is adjusted upward to 70.   If the
combined value is 64.4, the decimal fraction is disregarded
and the combined value of 64 is rounded off to 60.)

6.13.  Bilateral Factor.    When a partial disability
results from injury or disease of both arms, or both
legs, or of paired skeletal muscles, the ratings for
the disabilities of the right and left paired sides
are first combined in the standard manner.   Ten (10)
percent of the result (called the Bilateral Factor)
will be added to the first combined rating before proceeding
with further combinations, or converting to degree of
disability.   The Bilateral Factor is applied to the
bilateral disability combination before final combinations
with unpaired disabilities are carried out.   The rating
for a "Bilateral" disability (combined rating plus the
Bilateral Factor) is to be treated as one disability
rating when arranging multiple impairments in order
of severity prior to calculating further combinations.
  For example, with disabilities evaluated at 60 percent,
20 percent, 10 percent and 10 percent (the two 10s representing
bilateral disabilities), the order of severity would
be 60, 21 and 20.   The 60 and 21 combine to 68 percent
and the 68 and 20 to 74 percent, converted to 70 percent
as the final degree of disability.   (See paragraph
6.13.2., below, when there is more than one paired disability.)

6.13.1.  The terms "arms" and "legs" refer to the whole
upper and lower extremities respectively.   Thus, when
there is a compensable disability of the right thigh
(for example, amputation), and of the left foot (for
example, amputation of the great toe), the Bilateral
Factor applies.   Similarly, the Factor is applied whenever
there are compensable disabilities affecting use of
paired extremities regardless of location or specified
type of impairment, except as noted in paragraph 6.13.3.,
below.

6.13.2.  The correct procedure when applying the Bilateral
Factor to disabilities affecting both upper extremities
and both lower extremities is to combine the ratings
of the disabilities affecting the four extremities in
order of their individual severity and apply the Bilateral
Factor by adding 10 percent to the total combined value
thus attained.

6.13.3.  The Bilateral Factor is not applicable unless
there is an unfitting disability in each of two paired
extremities or paired skeletal muscles.   Special instructions
regarding the applicability of the Bilateral Factor
are provided in various parts of the VASRD.   For example,
codes 7114 - 7117 and codes 8205 - 8412.   The Bilateral
Factor is not applicable in skin disabilities rated
under code 7806.

6.14.  Use of VASRD Codes.    The VASRD code number
appearing opposite a listed disability indicates the
basis of the assigned valuation.   Code numbers are
also used for statistical analysis upon which policy
decisions may be made.   Great care must be exercised
in the selection of the applicable code and in its citation
on the rating sheet.

6.14.1.  Each rated disability is assigned a single
code number unless a hyphenated code is expressly authorized.
  It is not proper to use additional codes as a means
of further describing defects except as authorized by
the VASRD (e.g., in Gulf War cases).   The written diagnosis
entered on the rating sheet should include any description
considered necessary to indicate the extent, severity
or etiology of the coded condition.

6.14.2.  Injuries are generally assigned codes that
reflect the residual condition on which the rating is
based.

6.14.3.  Diseases are generally coded directly by the
number assigned to the disease itself.   If the rating
is determined on the basis of residual conditions, the
number appropriate to the residual condition will be
added, preceded by a hyphen.   Thus, atrophic (rheumatoid)
arthritis rated as ankylosis of the lumbar spine would
be "5002-5289".   The percentage rating in such cases
is reflected in the second number ("5289" in the example).
  In this way, the basis of each rating can be easily
identified.

6.14.4.  Hyphenated codes are used only:

6.14.4.1.  When the VASRD provides that a listed condition
is to be rated as some other code; e.g., myocardial
infarction rated as arteriosclerotic heart disease (7005-7006)
or nephrolithiasis rated as hydronephrosis (7508-7509).

6.14.4.2.  When the VASRD provides for a "minimum rating"
and the disability is being rated on residuals; e.g.,
multiple sclerosis rated as incomplete paralysis of
all unilateral upper extremity radicular groups (8018-8513)
in which case the minimal rating will be 30%.

6.14.4.3.  When an unlisted condition is rated by analogy,
e.g., spondylolisthesis rated as sacroiliac injury and
weakness (5299-5294).   If an unlisted disease, injury,
or residual condition is encountered, requiring rating
by analogy, the diagnostic code number will be "built-up"
as follows:   The first two digits will be selected
from that part of the schedule most closely identifying
the part, or system, of the body involved; the second
two digits will be “99”.   The resulting four-digit
number will be connected by hyphen to the code for the
analogous condition.   This procedure facilitates monitoring
of new and unlisted conditions.   (See Table of Analogous
Ratings, enclosure 3.)

6.14.4.4.  The DVA has prepared special analogous ratings
for "undiagnosed symptom complexes" associated with
Gulf War service.   (See Appendix of the Table of Analogous
Ratings.)

6.14.5.  In the narrative citation of disabilities on
rating sheets, the diagnostic terminology may be any
combination of the medical examiner's or VASRD terminology
which accurately reflects the degree of disability.
  Residuals of diseases or therapeutic procedures will
not be cited without reference to the basic disease.

6.15.  Rating principles for specific disabilities.
  Enclosure 2 provides instructions and explanatory
notes for rating certain disabilities.   This guidance
will be followed unless a subsequent change to the VASRD
makes the guidance obsolete.

7.  EFFECTIVE DATE 

This Instruction is effective immediately.

Enclosures - 3 

1.  Definitions

2.  Special Instructions and Explanatory Notes

3.  Table of Analogous Codes

E1.  ENCLOSURE 1

DEFINITIONS

E1.1.1.  Accepted Medical Principles.    Fundamental
deductions, consistent with medical facts that are so
reasonable and logical as to create a virtual certainty
that they are correct.

E1.1.2.  Accession Standards.    Physical standards
or guidelines that establish the minimum medical conditions
and physical defects acceptable for an individual to
be considered eligible for appointment, enlistment or
induction into the military Services (DoD Directive
6130.3, reference (e)).

E1.1.3.  Active Duty.    Full-time duty in the active
Military Service of the United States.   It includes:

E1.1.3.1.  Full-time National Guard Duty.

E1.1.3.2.  Annual training.

E1.1.3.3.  Attendance while in active Military Service
at a school designated as a Service school by law or
by the Secretary of the Military Department concerned.

E1.1.3.4.  Service by a member of a Reserve component
ordered to active duty (with or without his or her consent),
or active duty for training (with his or her consent),
with or without pay under competent orders.

E1.1.4.  Active Duty for a Period of More than 30 Days.
   Active duty or full-time National Guard Duty under
a call or order that does not specify a period of 30
days or less.

E1.1.5.  Active Reserve Status.    Status of all Reserves
who are not on an active-duty list maintained under
section 574 or 620 of 10 U.S.C. (reference (b)), except
those in the inactive National Guard or on an inactive
status list or in the Retired Reserve.   Reservists
in an active status may train with or without pay, earn
retirement points, and may earn credit for and be considered
for promotion.   In accordance with the Reserve Officer
Personnel Management Act (ROPMA), a member in an Active
Reserve status must be on the Reserve Active Status
List (RASL) (10 U.S.C. 14002, reference (b)).

E1.1.6.  Active Service.    Service on active duty or
full-time National Guard duty.

E1.1.7.  Compensable Disability.    A medical condition
determined to be unfitting by reason of physical disability
and which meets the statutory criteria under Chapter
61 of reference (b) for entitlement to disability retired
or severance pay.

E1.1.8.  Competency Board.    A board consisting of
at least three medical officers or physicians (including
one psychiatrist) convened to determine whether a member
is competent (capable of making a rational decision
regarding his or her personal and financial affairs).

E1.1.9.  Death.    A determination of death must be
made in accordance with accepted medical standards and
the laws of the State where the member is located or
the military medical standards in effect at an overseas
location.

E1.1.10.  Deployability.    A determination that the
member is free of a medical condition(s) that prevents
positioning the member individually or as part of a
unit, with or without prior notification to a location
outside the Continental United States for an unspecified
period of time.

E1.1.11.  Duty Related Impairments.    Impairments which,
in the case of a member on active duty for 30 days or
less, are the proximate result of, or were incurred
in line of duty after September 23, 1996, as a result
of:

E1.1.11.1.  performing active duty or inactive duty
training;

E1.1.11.2.  traveling directly to or from the place
at which such duty is performed; or

E1.1.11.3.  after September 23, 1996, an injury, illness,
or disease incurred or aggravated while remaining overnight,
between successive periods for purposes of IDT, at or
in the vicinity of the site of the IDT, if the site
is outside reasonable commuting distance of the member’s
residence.

E1.1.12.  Extended Active Duty.    Active duty under
orders specifying a period of more than 30 days.

E1.1.13.  Final Reviewing Authority.    The final approving
authority for the findings and recommendations of the
PEB.

E1.1.14.  Full and Fair Hearing.    A hearing held by
a board, before which the Service member has the right
to make a personal appearance with the assistance of
counsel and to present evidence in his or her behalf.

E1.1.15.  Impairment of Function.    Any disease or
residual of an injury that results in a lessening or
weakening of the capacity of the body or its parts to
perform normally, according to accepted medical principles.

E1.1.16.  Inactive Duty Training (IDT).    Duty prescribed
for Reservists, other than active duty or full-time
National Guard Duty, under 37 U.S.C. 206 (reference
(f)) or other provision of law.   It does not include
work or study in connection with a correspondence course
of a Uniformed Service.

E1.1.17.  Instrumentality of War.    A vehicle, vessel,
or device designed primarily for Military Service and
intended for use in such Service at the time of the
occurrence of the injury.   It may also be a vehicle,
vessel, or device not designed primarily for Military
Service if use of or occurrence involving such a vehicle,
vessel, or device subjects the individual to a hazard
peculiar to Military Service.   This use or occurrence
differs from the use or occurrence under similar circumstances
in civilian pursuits.   There must be a direct causal
relationship between the use of the instrumentality
of war and the disability, and the disability must be
incurred incident to a hazard or risk of the service.

E1.1.18.  Line of Duty Investigation.    An inquiry
used to determine whether an injury or disease of a
member performing military duty was incurred in a duty
status; if not in a duty status, whether it was aggravated
by military duty; and whether incurrence or aggravation
was due to the member's intentional misconduct or willful
negligence.

E1.1.19.  Natural Progression.    The worsening of a
pre-Service impairment that would have occurred within
the same timeframe regardless of Military Service.

E1.1.20.  Nonduty Related Impairments.    Impairments
of members of the Reserve components that were neither
incurred nor aggravated while the member was performing
duty, to include no incident of manifestation while
performing duty which raises the question of aggravation.
  Members with nonduty related impairments are eligible
to be referred to the PEB for solely a fitness determination
but not a determination of eligibility for disability
benefits.

E1.1.21.  Office, Grade, Rank, or Rating 

E1.1.21.1.  Office.    A position of duty, trust, authority
to which an individual is appointed.

E1.1.21.2.  Grade.    A step or degree in a graduated
scale of office or military rank that is established
and designated as a grade by law or regulation.

E1.1.21.3.  Rank.    The order of precedence among members
of the Armed Forces.

E1.1.21.4.  Rating.    The name (such as "Boatswain's
Mate") prescribed for members of an Armed Force in an
occupational field.

E1.1.22.  Optimum Hospital and Medical Treatment Benefits.
   The point of hospitalization or treatment when a
member's progress appears to be stabilized; or when,
following administration of essential initial medical
treatment, the patient's medical prognosis for being
capable of performing further duty can be determined.

E1.1.23.  Performing Military Duty of 30 days or less.
   A term used to inclusively cover the categories of
duty pertaining to 10 U.S.C. 1204 - 1206 (reference
(b)) (active duty, IDT, and travel directly to and from
active duty or IDT).

E1.1.24.  Permanent Limited Duty.    The continuation
on active duty or in the Ready Reserve in a limited
duty capacity of a Service member determined unfit as
a result of physical disability evaluation or medical
disqualification.

E1.1.25.  Physical Disability.    Any impairment due
to disease or injury, regardless of degree, that reduces
or prevents an individual's actual or presumed ability
to engage in gainful employment or normal activity.
  The term "physical disability" includes mental disease,
but not such inherent defects as behavioral disorders,
adjustment disorders personality disorders, and primary
mental deficiencies.

E1.1.26.  Preponderance of Evidence.    That evidence
that tends to prove one side of a disputed fact by outweighing
the evidence on the other side (that is, more than 50
percent).   Preponderance does not necessarily mean
a greater number of witnesses or a greater mass of evidence;
rather, preponderance means a superiority of evidence
on one side or the other of a disputed fact.   It is
a term that refers to the quality, rather than the quantity
of the evidence.

E1.1.27.  Presumption.    An inference of the truth
of a proposition or fact, reached through a process
of reasoning and based on the existence of other facts.
  Matters that are presumed need no proof to support
them, but may be rebutted by evidence to the contrary.

E1.1.28.  Presumption Period.    The designated time
frame that requires application of the Presumption of
Fitness Rule to a member's physical disability evaluation.

E1.1.29.  Proximate Result.    A disability the result
of, arising from, or connected with active duty, annual
training, active duty for training, or inactive duty
training (IDT), (etc.) to include travel to and from
such duty or remaining overnight between successive
periods of inactive duty training.   Proximate result
is a statutory criteria for entitlement to disability
compensation under Chapter 61 of 10 U.S.C. (reference
(b)) applicable to Reserve component members who incur
or aggravate a disability while performing an ordered
period of military duty of 30 days or less.

E1.1.30.  Ready Reserve.    Units and individual reservists
liable for active duty as outlined in Sections 12301
(Full Mobilization) and 12302 (Partial Mobilization)
of reference (b).   This includes members of units,
members of the Active Guard Reserve Program, Individual
Mobilization Augmentees, Individual Ready Reserve, and
the Inactive National Guard.

E1.1.31.  Retention Standards.    Physical standards
or guidelines which establish those medical conditions
or physical defects that may render a Service member
unfit for further Military Service and are therefore
cause for referral of the member into the DES.

E1.1.32.  Service Aggravation.    The permanent worsening
of a pre-Service medical condition over and above the
natural progression of the condition caused by trauma
or the nature of Military Service.

E2.  ENCLOSURE 2

SPECIAL INSTRUCTIONS AND EXPLANATORY NOTES

E2.1.  GENERAL 

E2.1.1.  This enclosure is a supplement to the VASRD
that contains principles for rating disabilities where
additional guidance or clarification is needed for processing
active duty and Reserve military disability cases. 
 Portions requiring special comment, or that have been
the cause of misunderstanding in the past, are included.
  Comments and rating instructions also supplement the
VASRD in those instances in which recent medical advances
are inadequately covered.   Supplements to the VASRD
published by the DVA following the effective date of
this Instruction shall take precedence unless the changes
included in the supplement are identified by the Assistant
Secretary of Defense for Health Affairs through a published
interim change to this Instruction to be inappropriate
to military requirements.

E2.1.2.  In adjudicating cases, the VASRD is the starting
point and initial guidance for an impairment rating.
  Because this enclosure modifies selected VASRD ratings,
it is the final reference for impairment adjudications.

E2.1.3.  Unless otherwise directed, separate disability
ratings are combined rather than mathematically summed.

E2.2.  NEW GROWTHS, MALIGNANT 

E2.2.1.  The policies contained in this paragraph apply
to malignant new growths except as modified by notes
for specific tumors.   Special consideration must be
given to determination of fitness or unfitness, since
many Service members are not disabled by these diseases,
their treatment, or the outcome.

E2.2.2.  A Service member with a diagnosed malignant
tumor that has metastasized, and has not FAVORABLY responded
to therapy, if unfit, SHALL be permanently retired,
at 100 percent if such rating is not expected to change
within the next 5 years.   In such cases, metastasis
may be defined as distant spread of the tumor or as
local invasion that renders treatment non-curative.

E2.2.3.  A Service member with a diagnosed malignant
tumor that has not metastasized and has responded favorably
to therapy to the extent that no current evidence of
the disease exists, NEED NOT BE FOUND UNFIT.   A Service
member who is functionally unfit because of residual
conditions secondary to treatment of a malignancy (e.g.,
chemotherapy, radiation therapy, and surgery) may be
rated using the Alphabetical Listing of Analogous Ratings
(enclosure 3).   The code for the relevant malignancy
should be listed first, followed by the analogous code(s).
  For example, the code for leukemia in remission associated
with fatigue secondary to chemotherapy would be "7703-6399-6354".
  Residuals shall be rated according to the applicable
VASRD code and not necessarily according to the code
for malignancy.   The minimal rating for the malignancy
does not apply.

E2.2.4.  A Service member who is undergoing chemotherapy
that constitutes the whole or part of definitive treatment
may be retained on active duty, placed on TDRL, or permanently
retired or separated, as indicated by individual circumstances.

E2.2.5.  When chemotherapy is used as an adjunctive
treatment and no evidence of an unfitting residual malignant
tumor exists, the use of chemotherapy will not necessarily
influence the disposition of the case unless adverse
effects of the chemotherapy have ensued.

E2.2.6.  Malignancies, including the leukemias, that
require bone marrow transplantation usually result in
a Service member being unfit and placed on the Temporary
Disability Retired List (TDRL) to be reevaluated at
18 months, or sooner if required.   A disability rating
awarded after a TDRL interim evaluation shall be based
on residual conditions.   If recurrent tumor is found,
permanent retirement at the appropriate disability rating
disability is indicated.

E2.3.  ORGAN TRANSPLANTS 

E2.3.1.  Joint prosthetic transplants are discussed
under codes 5051 through 5056.

E2.3.2.  Vascular system prosthetics are addressed under
the 7000 code.

E2.3.3.  Service members requiring transplant will ordinarily
be unfit due to organ failure.   The Service member
should be placed on the TDRL.   In those cases in which
a definite date has been set for transplantation, disposition
shall be postponed and residuals rated after the transplantation.

E2.3.4.  Those cases that have not come before the PEB
before transplantation shall be rated based on the following
factors:

E2.3.4.1.  The functional status of the transplanted
organ.

E2.3.4.2.  The need for sustained immunosuppression
or its adverse effects.   Adverse effects may be rated
on the basis of specific infections or by analogy (see
enclosure 3:   Table of Analogous Ratings).

E2.4.  ANTICOAGULANT PROPHYLAXIS OR TREATMENT 

E2.4.1.  The long-term use of anticoagulants will not
be the cause to increase the rating of a given medical
impairment.

E2.4.2.  Complications arising from the use of anticoagulants
should be given separate ratings.

E2.4.3.  Hypercoagulable states requiring chronic use
of anticoagulants shall be rated either at:

E2.4.3.1.  Zero percent if there has been no thrombophlebitis
or embolus in the past year; or,

E2.4.3.2.  At least 10 percent if there has been thrombophelebitis
or embolus in the past year.

E2.4.3.3.  A rating greater that ten percent shall be
based on unfitting residuals due to thrombophlebitis
or embolus.

E2.5.  HUMAN IMMUNODEFICIENCY VIRUS INFECTION (HIV)
AND/OR ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) 

Members found unfit for HIV and/or AIDS will be rated
according to the 6351 code and the rating scheme in
the VASRD.   The minimum rating of 30 percent, which
existed prior to the establishment of the VASRD Code
6351, is no longer in effect.

E2.6.  GULF WAR CASES 

E2.6.1.  Military personnel who served in the Southwest
Asia theater of operations (from August 2, 1990, through
a date to be determined) and who are unfit for a diagnosis
of “undiagnosed illness” shall be rated in accordance
with the VASRD rating guidance for “undiagnosed illnesses.”

E2.6.2.  A two-part hyphenated code is used to describe
the unfitting condition.   The FIRST PART is composed
of a prefix of "88" combined with the first two numbers
of the body system to which the unfitting symptoms most
closely relate.   The SECOND PART of the code is the
medical condition, in the code series indicated by the
second two numbers of the first part of the code, that
most closely resembles the Service member's circumstances.
  For example, the first part of the code to describe
a case in which the predominant symptom is fatigue could
be 8863.   The second part is the medical condition
in the 6300 series that most closely resembles that
of the Service member.   In that example, the code "6354"
is used.   Thus, the case is rated by analogy to “Chronic
Fatigue Syndrome”.   The resulting code is "8863-6354".

E2.6.3.  Two requirements must be met to justify using
the coding system described in paragraph E2.6.2., above.

E2.6.3.1.  The Service member is suffering a symptom
complex that is not reasonably definable using currently
acceptable diagnostic nomenclature (an "undiagnosed
symptom complex"); and,

E2.6.3.2.  The Service member is unfit because of the
"undiagnosed symptom complex."

E2.7.  NECROTIZING FASCIITIS 

E2.7.1.  Those cases in which the condition has a systemic
effect should be rated according to the Alphabetical
Listing of Analogous Ratings (enclosure 3).

E2.7.2.  If the systemic component has overwhelmed the
Service member's endogenous immune system, the disability
should be rated at 100 percent and the Service member
placed on the TDRL.   Ratings at final disposition shall
be based on residuals. 

   

Service members with cardiac, vascular or neurosurgical
conditions that require indwelling foreign bodies (e.g.,
pacemakers, defibrillators, venous umbrellas, and venrticulo-peritoneal
shunts) who are unfit should be rated at a minimum of
30%.

E2.8.  FIBROMYALGIA 

E2.8.1.  This condition must be evaluated by a rheumatologist
and meet the requirements of paragraph E2.A1.1.5.2.,
below.

E2.8.2.  The diagnostic criteria put forth by the American
College of Rheumatology must be met.

   

As medicine advances, new diagnoses will emerge. Those
diagnoses generally accepted by the medical profession
(or by a respectable minority of the profession) shall
be rated by analogy until the diagnoses become incorporated
in the VASRD.

Attachments - 1

1.  Instructions for Specific VASRD Codes

E2.A1.  ATTACHMENT 1 TO ENCLOSURE 2

INSTRUCTIONS FOR SPECIFIC VASRD CODES

E2.A1.1.  5000 Series 

E2.A1.1.1.  5000.   Osteomyelitis 

E2.A1.1.1.1.  Saucerization or sequestrectomy does not
necessarily equate with stabilization or cure.

E2.A1.1.1.2.  Osteomyelitis extending into a major joint
is rated in accordance with the amputation rule.

E2.A1.1.2.  5002.   Rheumatoid Arthritis 

E2.A1.1.2.1.  Active process: The rating is based on
clinical and laboratory features and coded under 5002.

E2.A1.1.2.2.  Chronic residuals are rated under appropriate
limitation of motion codes (5200 series).   Chronic
residuals shall be based on clinical features plus radiographic
evidence.

E2.A1.1.2.3.  The bilateral factor is applied when appropriate.

E2.A1.1.2.4.  Ratings for active disease process (5002)
should not be combined with ratings for residuals (5200
series).

E2.A1.1.2.5.  Pulmonary involvement is rated separately
under 6802.

E2.A1.1.2.6.  Enteropathies are rated separately under
the 7300 series.

E2.A1.1.3.  5003.   Arthritis, Degenerative, Hypertrophic,
and Pain Conditions Rated by Analogy to Degenerative
Arthritis 

E2.A1.1.3.1.  Each major joint (or grouping of minor
joints) with objective limitation of motion plus radiographic
evidence is rated at 10 percent.   (The bilateral factor
applies.)

E2.A1.1.3.2.  Radiographic evidence of two or more major
joints or groups of minor joints, when accompanied by
occasional exacerbations of incapacitating symptoms,
is given a total rating of 20 percent.   Radiographic
evidence alone without symptoms is rated at 10 percent.
  (No Bilateral Factor applies.)

E2.A1.1.3.3.  Limitation of motion of affected joints
may warrant rating under 5200 series or 9905.   (Bilateral
Factor applies.)

E2.A1.1.3.4.  In cases in which there is a limitation
of motion not of sufficient degree to rate under the
5200 series or 9905, the rating shall be done under
5003.

E2.A1.1.3.5.  For rating purposes, combinations of interphalangeal,
metacarpal-phalangeal, and metatarsal-phalangeal joints
are groups of minor joints equivalent to a major joint.

E2.A1.1.3.6.  5285-5295.   The spine:   Each segment
of the spine (cervical, dorsal, and lumbar) segments
is regarded as a group of minor joints.   Combination
of sacroiliac and lumbosacral joints is regarded as
a major joint.   Each group of minor joints is ratable
as one major joint only when separate ratings are justified
by Radiographic evidence of pathology besides limitation
of motion or other evidence of painful motion of the
individual segments involved.

E2.A1.1.4.  5004-5009-5017-5024.   Arthritis, Miscellaneous.
   5004-5009-5017 are rated according to Code 5003.
  The remainder, including all of the septic, infectious,
or other arthritides, are rated on the basis of associated
constitutional symptoms according to VASRD codes 5002.
  Reiters syndrome, spondylitis, transplantation antigen-related
arthritis, or arthritis secondary to bowel disease are
examples.

E2.A1.1.5.  5025.   Fibromyalgia 

E2.A1.1.5.1.  Fibromyalgia (also called fibrositis,
myofascial pain syndrome, or primary fibromyalgia syndrome),
is a syndrome of chronic, and widespread musculoskeletal
pain associated with multiple tender or "trigger" points,
and is often accompanied by multiple somatic complaints.
  It is a condition for which diagnostic criteria were
formally established in 1990.

E2.A1.1.5.2.  Diagnostic criteria include the following:

E2.A1.1.5.2.1.  A history of widespread pain that has
been present for at least 3 months.   There must be
both axial skeletal pain and peripheral pain.

E2.A1.1.5.2.2.  The presence of pain on digital palpation
at 11 of 18 tender point sites.

E2.A1.1.5.2.3.  The presence of a second clinical disorder
does not exclude the diagnosis.

E2.A1.1.5.2.4.  That diagnosis should have been made
by or with the consultation of a rheumatologist.

E2.A1.1.6.  5051-5056.   Prosthetic Implants 

E2.A1.1.6.1.  Those do not necessarily render a Service
member unfit.

E2.A1.1.6.2.  If a Service member is considered to be
unfit at the time of a Physical Evaluation Board, placement
on TDRL should be considered.

E2.A1.1.6.3.  If the Service member is still found to
be unfit at TDRL reevaluation, a permanent rating should
be considered based on residual impairment.   In such
cases the amputation rule applies, but convalescent
ratings do not apply.

E2.A1.1.7.  5126-5151.   Multiple Finger Disabilities.
   A convenient method of computation has made the difficulty
often encountered in rating multiple finger disabilities
simpler.   An "average amputation level" for fingers
involved may be calculated by assigning graded values
for each finger according to the level at which it was
amputated (See Table 1 and Plate III).   Graded values
may also be assigned for the severity of a finger's
ankylosis.   The disability may then be rated according
to the notes of instruction in the VASRD.   The method
is as follows:

E2.A1.1.7.1.  Step One.    The appropriate grade value
for each of the individual finger defects is selected
by referring to figure 1 and by matching the appropriate
description in column A of table 1 with the corresponding
value in column C.   These values are ADDED together
(totaled).

E2.A1.1.7.2.  Step Two.    The average grade value is
found by dividing the totaled values for the individual
fingers by the number of fingers involved.   Fractions
are rounded to the nearest whole number.

E2.A1.1.7.3.  Step Three.    The category of defects
(favorable ankylosis, unfavorable ankylosis, and amputation)
applicable to the multiple finger disabilities taken
as a whole is found in column B by matching with the
previously calculated average grade value in column
C.

E2.A1.1.7.4.  Step Four.    The correct disability percentage
rating is arrived at by referring to the VASRD code
that addresses the category of defects found in step
three and calculating for the number of fingers involved.

E2.A1.1.7.5.  Example:    An evaluee has had the following
amputations:   thumb amputated through the middle phalanx;
index and little fingers through the middle phalanges;
and the entire ring finger, including more than one-half
of the metacarpal.

Grade Value for the thumb

  2

Grade Value for index finger

  2

Grade Value for little finger

  2

Grade Value for ring and metacarpal

  4

Total Value

10

Total value/Number of fingers involved = ratable value
10/4 = 2 1/2 = 3

Referring to table 1, grade 3 is ratable as amputation.
  Amputation of four fingers (thumb, index, ring, and
little) is ratable under VA code 5127 at 70 percent
for major hand, or 60 percent for minor hand.

E2.A1.1.7.6.  For rating purposes, the thumb is regarded
as having no distal phalanx.   Amputation of the thumb
at or distal to the interphalangeal joint shall be graded
as unfavorable ankylosis (grade value 2).

E2.A1.1.8.  5171.   Amputation of Great Toe.    Must
be through the proximal phalanx to warrant a 10 percent
rating.

E2.A1.1.9.  5200-5295.   Rating Involving Joint Motion


E2.A1.1.9.1.  In measuring joint motion it is incumbent
on the medical examiner to utilize the standardized
description portrayed in figures 2 and 3.

E2.A1.1.9.2.  When the reported limited range of motion
falls between two points specified in the VASRD, the
higher percentage of disability is applied.

E2.A1.1.9.3.  Ankylosis is the absence of motion of
a joint.   For disability rating purposes, it is complete
fixation, or a limitation of motion so severe in degree
that the amount of movement is negligible.

E2.A1.1.9.4.  Use of analogies such as "other impairment
of" elbow or knee (code 5209 or 5257), is to be avoided
when the actual impairment is a limitation of motion
of the joint, properly ratable as limitation of flexion
or extension of the part distal to the joint.

E2.A1.1.9.5.  In some cases of limitation, or of other
abnormal joint motion, the basic cause is injury to
muscle or tendon rather than to bone or joint.   A careful
distinction must be made for appropriate rating.

E2.A1.1.10.  5205-5208.   Ankylosis or Limitation of
Motion of Elbow and Forearm 

E2.A1.1.10.1.  5205.    When a rating for unfavorable
ankylosis is not based on the additional finding of
complete loss of supination or pronation, the rating
may be combined with 5213, subject to the amputation
rule.   If less then complete loss of supination or
pronation occurs, 5205 may be combined with 5213, but
the percentage must not exceed the rating for unfavorable
ankylosis under 5205.

E2.A1.1.10.2.  5206-5208.    These codes may be combined
with 5213, but the percentage must not exceed the rate
for unfavorable ankylosis under 5205.   If residuals
exceed the maximum rating allowable under 5205 or 5209,
the rating for amputation below insertion of the deltoid
(5122) may be used.

E2.A1.1.10.3.  Codes 5209-5212 should not be combined
with code 5213.

E2.A1.1.11.  5213.   Impairment of Pronation and Supination


E2.A1.1.11.1.  The following terminology for describing
measurements of pronation and supination must be used,
when assessing impairment, to facilitate uniformity
of disability ratings.

E2.A1.1.11.1.1.  The STARTING POINT for all motions
of pronation and supination shall be zero degrees (thumb
on the upper side of the hand with the hand held perpendicular
to a flat surface).   Supination is that motion between
the starting point and palm up position.   Pronation
is that motion from the starting point to palm down.

E2.A1.1.11.1.2.  Full supination is 80 degrees of motion
from the starting point.   Full pronation is 80 degrees
of motion from the starting point.

E2.A1.1.11.1.3.  Position of function is 20 degrees
pronation (AMA guide).

E2.A1.1.11.2.  VASRD rating 5213.

E2.A1.1.11.2.1.  The hand is fixed in full supination
with the palm up.

E2.A1.1.11.2.2.  Hyperpronation continues beyond the
80 degrees of full pronation with the thumb down.

E2.A1.1.11.2.3.  The hand fixed in full pronation is
fixed with palm down.

E2.A1.1.11.2.4.  The VASRD term "middle of arc" is equivalent
to zero degrees.

E2.A1.1.11.2.5.  The VASRD term "beyond the last quarter
of the arc" is equivalent to the inability to pronate
beyond 40 degrees from the starting point.

E2.A1.1.11.3.  Limitation of either pronation or supination
may be rated. However, both should never be rated in
the same arm.   The higher rating applies.

E2.A1.1.12.  5214.   Wrist, Ankylosis of 

E2.A1.1.12.1.  Ankylosis of the wrist in 10 degrees
to 30 degrees of dorsiflexion shall be considered favorable
and rated accordingly.

E2.A1.1.12.2.  Wrist replacement prostheses are rated
according to functional impairment.

E2.A1.1.13.  5215-5253.   Limitation of Extension and
Flexion of the Thigh.    Ratings allowable under those
codes may not accurately reflect the degree of disability
in circumstances where limitation of motion may reflect
a more serious underlying disability of the sacroiliac
region, pelvis, acetabulum, or head of the femur.  
The variability of residuals following injuries to these
structures necessitates rating specific residuals; e.g.,
faulty posture, limitation of motion, muscle injury,
painful motion of the lumbar spine, mild to moderate
sciatic neuritis, peripheral nerve injury, or limitation
of hip motion.   More suitable ratings may be selected
from VA code 5250 (hip, ankylosis of), VA code 5255
(femur, impairment of, with hip disability), or VA code
5294 (sacroiliac injury).

E2.A1.1.14.  5255-5262.   Defects of Long Bones of the
Lower Extremity.    These codes (malunion with adjacent
joint disability) should be applied when appropriate,
to avoid multiple codes and ratings.   When both a proximal
and a distal major joint are affected, however, an additional
rating may be indicated for the less disabled joint.
  Those codes are often appropriate when joint surfaces
are included in fracture lines.

E2.A1.1.15.  5257.   Knee, Other Impairments 

E2.A1.1.15.1.  Patellectomy, chondromalacia, osteochondritis
dissecans should be rated under 5003.   Exceptions are
cases in which objective findings warrant rating under
code 5257.

E2.A1.1.15.2.  Recurrent subluxation or external instability.

E2.A1.1.15.2.1.  A rating of 30 percent for severe knee
instability is awarded in those cases where a Lachman's
test of ligament instability-to-stress test reveals
a reading in excess of 3+ and where a knee brace, usually
a derotation brace, is prescribed for a functional as
opposed to a protective purpose.   Specifically, a functional
knee brace supplements or replaces the function of a
major ligament or ligaments required for stability.
  Laxity in a effected knee must be compared to that
of the unaffected knee to determine deviation caused
exclusively by the medical condition.

E2.A1.1.15.2.2.  A rating of 20 percent for moderate
instability is awarded in those cases where the Lachman's
test measures an instability reading of 2+ and physical
therapy results in no improvement of the knee's lateral
instability.

E2.A1.1.15.2.3.  A rating of 10 percent for slight knee
instability is appropriate in cases where the Lachman's
test measures an instability reading between 1+ and
2+ and physical therapy does not improve the knee's
lateral instability.

E2.A1.1.15.2.4.  Knee joint replacement shall be rated
according to code 5055.

E2.A1.1.16.  5285-5295.   The Spine 

E2.A1.1.16.1.  Each segment of the spine (cervical,
dorsal, and lumbar) segments is regarded as a group
of minor joints.   Combination of sacroiliac and lumbosacral
joints is regarded as a major joint.   Each group of
minor joints is ratable as one major joint only when
separate ratings are justified by radiographic evidence
of pathology besides limitation of motion or other evidence
of painful motion of the individual segments involved.

E2.A1.1.16.2.  Arthritic impingement on nerve roots
produces degeneration of the nerve function or frequent,
prolonged attacks of neuralgia.   These attacks are
to be distinguished from brief episodes of radicular
pain.   The arthritic impingement should be rated as
one entity under codes for neurologic conditions.  
The exception is a case in which limitation of spinal
motion justifies an additional rating.

E2.A1.1.17.  5285.   Residuals of Fracture of Vertebra


E2.A1.1.17.1.  The need for a Service member to wear
some type of brace to restrict lumbar or dorsolumbar
movement is not similar to the requirement for a jury
mast type of neck brace for abnormal mobility after
cervical fracture.   When no cord involvement is evident,
the disability should be rated according to the degree
of limited motion with brace in place.

E2.A1.1.17.2.  The 10 percent addition to the rating
is made only for demonstrable, substantial deformity
of a vertebral body (i.e., visible to the naked eye
and greater than 50 percent compression on a X-ray).
  It should not be added in those instances of insignificant
deformity such as slight shortening of the anterior
vertical dimension of the vertebral body.   When a successful
spinal fusion has been performed because of the deformity,
the degree of instability has usually been removed,
or so far reduced that the addition of 10 percent is
not justified.   An extensive spinal fusion may result
in a ratable limitation of motion.

E2.A1.1.18.  5286-5289.   Ankylosis of a Spinal Segment


E2.A1.1.18.1.  A rating for ankylosis is given only
when the range of motion of the whole spinal segment
is absent or negligible.   Ankylosis of a part of a
segment may leave some degree of useful motion for the
segment as a whole.   In such cases the appropriate
rating would be for limitation of motion.

E2.A1.1.18.2.  The combination of separate ratings for
ankylosis of a spinal segment shall not exceed 60 percent
of the rating for complete ankylosis of the spine at
a favorable angle.

E2.A1.1.19.  5293.   Intervertebral Disc Syndrome. 
  The intervertebral disc syndrome involves a herniation
of the nucleus pulposus with impingement on the nerve
root resulting in irritation and a radicular distribution
of pain.

E2.A1.1.19.1.  In view of the fact that 40 percent -
50 percent of the population have herniated discs which
are asymptomatic, finding a herniated disk on MRI in
a Service member with back pain does not necessarily
imply the herniated disk is the primary cause of the
pain.

E2.A1.1.19.2.  Ratings of 40 percent - 60 percent will
be predicated upon objective neurological findings supported
by laboratory data, such as EMG, nerve conductive studies,
flow and manometric studies for bowel and bladder involvement.

E2.A1.1.19.3.  The weight attached to each finding shall
vary according to the co-presence of other findings.

E2.A1.1.19.4.  Surgical excision of a disc without evidence
of recurrent disc herniation at the same level or a
different level precludes the application of the 5293
code.

E2.A1.1.19.5.  Residual cervical pain with radiculopathy,
status post excision of a herniated disc should be rated
for the pain (5003) or limitation of motion (5290) and
for the radiculopathy under the appropriate 8500 series
code.

E2.A1.1.19.6.  Residual lumbar pain with radiculopathy
should be rated as 5295 and the relevant code for neurological
impairment.

E2.A1.1.20.  5295.   Lumbosacral Strain 

E2.A1.1.20.1.  Zero percent rating shall be awarded
for chronic low back pain of unknown etiology (mechanical
low back pain).

E2.A1.1.20.2.  Demonstrable pain on spinal motion associated
with positive radiographic findings shall warrant a
10 percent rating.   If paravertebral muscle spasms
are also present, a 20 percent rating may be awarded.
  Such paravertebral muscle spasms, however, must be
chronic and evident on repeated examinations.

E2.A1.1.21.  5296.   The Skull 

E2.A1.1.21.1.  Areas of loss where bone regeneration
has taken place are not ratable.   If regeneration has
partially closed the defect, only the remaining area
of loss is to be rated.

E2.A1.1.21.2.  Total bone loss from a single area of
the skull is not ratable if the defect has been successfully
repaired with a prosthetic plate.   Residual neurological
deficit or cosmetic deformity shall be rated separately
if appropriate.

E2.A1.1.21.3.  The following conversion measurements
shall be used in applying VASRD ratings:

E2.A1.1.21.3.1.  Defect of a diagnostic burr hole approximates
one square centimeter.

E2.A1.1.21.3.2.  A 25 cent piece (quarter) = 4.6 square
centimeters.

E2.A1.1.21.3.3.  A 50 cent piece (half dollar) = 7.35
square centimeter.

E2.A1.1.21.3.4.  Diagnostic burr holes and other bony
defects are ratable only when contiguous and when there
is loss of both inner and outer tables of bone.   The
areas are added and the total is rated.

E2.A1.1.21.3.5.  When there is total bone loss from
multiple areas, such as in trephining, the rating should
not be assigned based upon "coin measurement" but on
the basis of the aggregate area of loss in terms of
square centimeters.

E2.A1.1.21.3.6.  Suboccipital skull defects shall not
be rated.

E2.A1.1.22.  5297.   Removal of Ribs 

E2.A1.1.22.1.  For removal of ribs, the VASRD requires
the complete removal from the vertebral angle to the
costo-cartilaginous junction.   Removals of a lesser
degree are rated as rib resections.

E2.A1.1.22.2.  The presence of certain conditions precludes
the assignment of an additional rating under Code 5297;
exceptions are allowed in specific situations.   “Notes
(1)” and “(2)” under this code in VASRD provide pertinent
guidance.

E2.A1.1.23.  5003-5279.   Stress Fractures 

E2.A1.1.23.1.  Since the VASRD has no specific rating
schedule for these conditions, rating shall be done,
as follows:

E2.A1.1.23.1.1.  If there is radiographic evidence of
fracture of the femur or tibia, it should be rated as
any other fracture.   The Bilateral Factor would apply,
if appropriate.

E2.A1.1.23.1.2.  Fracture of the pubic rami confirmed
by radiographic findings should be rated under 5003.
  That is a membranous bone that can be expected to
heal quickly.   Muscle action of the large thigh adductors
is the main aggravating force, not weight bearing.

E2.A1.1.23.1.3.  Fracture of tibial and fibular malleoli
are seldom displaced, may not require surgery, and except
for offering some comfort, casts are not required. 
 The most appropriate rating would be analogous to 5262,
slight.

E2.A1.1.23.1.4.  Stress fracture of the tarsals or metatarsals
should be rated under 5279, metatarsalgia.

E2.A1.1.23.1.5.  Tibial plateau and femoral condyle
stress fractures are stable unicortical defects which
should be rated as analogous to 5259 because of some
impairment of knee function.   The use of the 5257 would
be inappropriate because the lesion is extra-articular
and produces pain, not knee instability.

E2.A1.1.23.1.6.  Stress reaction without radiographic
evidence of fracture should be rated as periostitis
under 5022.

E2.A1.1.23.2.  Radiographic Evidence.    At the time
of the original MEB, a Service member may have pain
not explained by routine radiographic examination. 
 A bone scan, however, may reveal increased vascularity
consistent with stress fracture or stress reaction.
  After a year, only routine radiographs are necessary
to demonstrate that there is or is not evidence of a
healed fracture.   There is no need for a bone scan.
  If the Service member originally had a fracture, it
will be evident on the radiograph.   If the current
radiographic is normal, then a fracture did not exist
at the time of the MEB.   The most likely diagnosis
was stress reaction.

E2.A1.1.23.3.  Service members who develop stress fractures,
especially of the femoral neck, during basic training
which prevents them from completing basic should be
separated with appropriate rating as the injury most
likely will recur when the Service member is recycled.

E2.A1.1.24.  5301-5326.   Muscle Injuries 

E2.A1.1.24.1.  Pyramiding must be avoided.   For example,
separate ratings should not be given for an ankylosed
joint and an injured muscle acting on that joint.

E2.A1.1.24.2.  Ratings for bone and joint impairment
should not be combined with ratings for muscle and nerve
impairments affecting the same joint.

E2.A1.2.  6000 Series 

E2.A1.2.1.  6000-6092.   Diseases of the Eye 

E2.A1.2.1.1.  The adjudication of disabilities of the
visual apparatus is difficult.   In some cases involving
a combination of defects, it may not be possible to
arrive at an equitable percentage rating through literal
application of the terms of the VASRD.   The complexity
of those conditions does not permit the construction
of a simple schedule that is adequate for the variety
of defects and resulting types and degrees of impairment
that may occur.   Here, the concept of "visual efficiency"
may be helpful.   Visual efficiency is the product of
the interdependent relationship of all the functions
of the ocular apparatus, of which the three principal
ones are central visual acuity, field of vision, and
muscle function.   Since the estimation of visual efficiency,
as such, is not provided by the VASRD as a means of
determining a degree of disability, it is useful only
to determine the Service member's real functional handicap
so that an equitable rating in terms of the schedule
can be recommended.

E2.A1.2.1.2.  The VASRD provides that the combined disabilities
of the same eye are not to exceed the rating for total
loss of vision of that eye, unless there is an enucleation
or a serious cosmetic defect added to the total loss
of vision.   Accordingly, where there is a cosmetic
defect, even though limited to the eye with the visual
loss, representing a separate and distinct entity, namely,
facial disfigurement, a separate rating of 10, 30, or
50 percent is permitted under 7800 to be combined with
the rating for visual loss or rating for enucleation.

E2.A1.2.1.3.  Visual field defects must be reported
according to the method prescribed in the VASRD, paragraphs
4.76 and 4.76a.   Results of muscle function examinations
should be reported in accordance with VASRD, paragraph
4.77.   Reference to the AMA Guides to the Evaluation
of Permanent Impairment (4th ed.) may assist in computing
the extent of impairment.

E2.A1.2.1.4.  When computerized techniques are used
to determine the extent of diplopia, visual fields,
or scotomata, the results must be interpreted in relation
to the standard VASRD charts to render a rating.

E2.A1.2.2.  6000-6009.   Conditions Involving Structures
of the Globe 

E2.A1.2.2.1.  Disabilities resulting from these conditions
are rated as follows:

E2.A1.2.2.1.1.  STEP ONE: 

E2.A1.2.2.1.1.1.  Impairment of visual acuity is rated.

E2.A1.2.2.1.1.2.  Impairment of field of vision is rated.

E2.A1.2.2.1.1.3.  Active pathology, if present, is rated
at 10 percent.

E2.A1.2.2.1.1.4.  The higher of the ratings in (1) and
(2) is combined with (3).

E2.A1.2.2.1.2.  STEP TWO:    Pain, rest requirements
and/or episodic incapacity are rated from 10 to 100
percent.   This rating, when only one eye is involved,
is not necessarily limited to the 30 percent rating
for total loss of vision of one eye, since pain or rest
requirements may be incapacitating to any degree, including
total.   This rating is assigned the code which covers
the basic condition (i.e., Code 6000 through 6009).
  Analogy to another code is not required.   It is an
estimate based as nearly as possible upon the actual
impairment of social and industrial function which is
imposed by the pain experienced, the time lost because
of the requirement for rest, the frequency of incapacitating
episodes, or any combination thereof.   The additional
rating of 10 percent for continuance of active pathology
should not be combined with this rating.

E2.A1.2.2.1.3.  STEP THREE:    The higher of the ratings
resulting from Steps One and Two, is awarded.

E2.A1.2.2.2.  Retained foreign body is rated as active
pathology as in Step One, above, if in a critical area
or not stabilized.   Otherwise, the rating is for residuals
under Step Two.

E2.A1.2.3.  6013.   Glaucoma, Simple, Primary, Noncongestive.
   The minimum rating is applicable if the diagnosis
is satisfactorily established, whether or not visual
acuity or field of vision has been affected.   The rating
is for the disease, rather than for functional impairment
of an individual organ, and applied whether the disease
progresses or not.

E2.A1.2.4.  6029.   Aphakia. Process Involves One or
Both Eyes.    This condition is usually not unfitting.
  However, requirements of a particular military occupational
skill must be considered in making a fitness determination.
  If the member is determined unfit, the appropriate
rating shall be applied.   The condition, if corrected
by successful prosthetic implants (pseudophakia), is
not considered unfitting or ratable unless the prosthetics
are specified as too unstable to withstand duty stress.

E2.A1.2.5.  6081.   Scotoma, Pathological.    The rating
is 10 percent whether unilateral or bilateral.   Other
ratings may be combined with the reservation that the
rating for one eye may not exceed 30 percent, unless
there is enucleation or a serious cosmetic defect. 
 Central scotoma cannot, however, be combined with central
visual loss.

E2.A1.2.6.  6090-6092.   Diplopia.    The VASRD uses
the Goldman Perimeter Chart to describe the location
in the field of vision where diplopia occurs.   The
VASRD, under 6090-6092, converts the location in the
field of vision where diplopia occurs to an equivalent
visual acuity that then can be used in the final rating.
  The final rating is achieved by referring to VASRD
Table V “Ratings for Central Visual Acuity Impairment”.
  The equivalent visual acuity is substituted for the
actual visual acuity of the worse eye (if visual acuity
is the same in both eyes, one eye will arbitrarily be
considered worse), and plotted against the actual visual
acuity of the better eye.   The intersecting box provides
the percentage rating and the VASRD code.

E2.A1.2.7.  6309.   Rheumatic Fever.    When a member
is determined to be unfit because of recurrence of disease,
the member may be rated at zero percent (see VASRD paragraph
4.31) if there is no residual functional impairment.
  If residual functional impairment is diagnosed, the
member shall be rated accordingly under the proper code.

E2.A1.2.8.  6350.   Lupus Erythematosus, Systemic. 
  Connective-tissue diseases, such as vasculitis, collagen
disease, immune complex disease, and other disseminated
diseases, not elsewhere covered, are to be rated under
that code.

E2.A1.2.9.  6351.   Human Immunodeficiency Virus Infection
(HIV) and Acquired Immune Deficiency Syndrome 

E2.A1.2.9.1.  That is the only code used in rating HIV
or AIDS.

E2.A1.2.9.2.  The rating criteria shall be according
to the VASRD.   The Service member must be determined
to be unfit because of that condition before rating.
  Seropositivity alone is not unfitting.

E2.A1.2.10.  6354.   Chronic Fatigue Syndrome 

E2.A1.2.10.1.  These cases must meet the definition
put forth by the National Institutes of Health (NIH
Publication No. 92-484).   Both major criteria and eight
or more of the minor criteria must be met.   "Incapacitation"
means that the Service member requires bed rest and
treatment by a physician.

E2.A1.2.10.2.  An active duty Service member referred
to the respective service DES (disability evaluation
system) for Chronic Fatigue Syndrome must have been
thoroughly evaluated.   The referring MEB shall include
a psychiatric evaluation, unit commander assessment,
report of observation in a hospital setting, other observer
(peers, et. al.) accounts, and interpretation of the
results of (at least) the following laboratory tests:
  blood tests, including CBC; Differential; WBC; ESR;
liver function tests; albumin; globin; calcium; phosphate;
electrolytes; glucose; BUN; greatinine; thyroid studies,
and urinalysis.

E2.A1.2.10.3.  The fatigue symptoms may be part of the
underlying psychiatric disorder.   In such cases, the
psychiatric disorder rather than Chronic Fatigue Syndrome
should be assessed as the potentially unfitting condition.
  If the Service member is rated separately for Chronic
Fatigue Syndrome and the psychiatric disorder, pyramiding
would result.   However, if the Service member has a
psychiatric disorder that is clearly separate from a
coexisting Chronic Fatigue Syndrome that is validly
based on NIH diagnostic criteria, both conditions should
be assessed and rated as to impact on fitness.

E2.A1.2.11.  6519.   Aphonia, Organic.    Impairment
of ability to speak may be ratable under more than one
code, depending on the cause and severity of the impairment.
  In such instances, the highest applicable rating is
awarded.   This Instruction does not apply to speech
impairment due to loss of whole or part of tongue that
is rated under Code 7202.

E2.A1.2.12.  6600-6630.   Disease of the Trachea and
Bronchi.    Unless contra- indicated, pulmonary function
tests, performed both with and without medication, must
confirm the clinical diagnosis and severity (See Table
2).   If the Service member's condition is subject to
significant variation over time, a single clinical and
pulmonary function evaluation may not be adequate. 
 Response to therapy is to be considered in all cases.
  The following pulmonary function test values serve
as guidelines in determining ratings (See Table 2).

E2.A1.2.13.  6701-6704; 6730-6732.   Active Tuberculosis.
   Active tuberculosis shall be rated under code 6730.
  All periods of time specified in the VASRD for the
management of tuberculosis, active or inactive, apply
only to the VA and do not apply to the military.   Treatment
and clinical response shall serve as the criteria for
disposition.   Rating for residuals shall be based on
functional impairment.

E2.A1.2.14.  6721-6724; 6731.   Inactive Pulmonary Tuberculosis


E2.A1.2.14.1.  Determining Inactivity.    Pulmonary
tuberculosis is considered to be inactive when:

E2.A1.2.14.1.1.  There are no symptoms of tuberculous
origin.   Serial roentgenograms show stability or very
slow shrinkage of the tuberculous lesion.   There is
no evidence of cavitation.   Sputum or gastric washings
show negative on culture or guinea pig inoculation.
  Those conditions shall have existed for at least 6
months.

E2.A1.2.14.1.2.  Established by evaluation.   That is
usually, but not always, at the time the patient is
declared to have received the maximum benefits of hospitalization.

E2.A1.2.14.1.3.  Six months have passed since surgical
excision of an active lesion during which time there
shall have been no evidence of tuberculous activity
in any body system.

E2.A1.2.14.2.  Chemotherapy.    Treatment by medication
is frequently continued beyond the date when the disease
becomes inactive according to the above criteria.  
The ending date of such treatment does not define the
beginning of the inactive status.

E2.A1.2.14.3.  Rating Residuals.    A rating of 100
percent for 1 year after the date of attaining inactivity
shall not be used.   After the condition becomes inactive,
residuals (e.g., impairment of pulmonary function, surgical
removal or resection of a part) should be rated under
the appropriate VA Code, subject to the limitations
contained in paragraphs 4.96a and b of the VASRD.

E2.A1.2.15.  6803-6806, 6808.   Mycotic Pulmonary Infections.
   Active disease is rated by analogy to code 6821.

E2.A1.2.16.  6807.   Aspergilloses of Lung.    That
code refers only to invasive aspergillosis or to aspergilloma.
  Active or recurrent allergic aspergillosis is rated
by analogy to code 6602 (asthma) raised to next higher
level (e.g., "mild" active aspergillosis would be rated
as "moderate" asthma).   Permanent residuals of allergic
aspergillosis are rated analogous to code 6802.

E2.A1.2.17.  6810.   Pleurisy, Serofibrinious.    Significant
ventilatory impairment is rated as analogous to code
6811.

E2.A1.2.18.  6814.   Pneumothorax.    The “100 percent
6 months” rating should not be applied.   A known underlying
condition may be rated.   If there is none, rating may
be analogy to emphysema (code 6603) or pneumoconiosis
(code 6802).

E2.A1.2.19.  6815.   Pneumonectomy.    Pneumonectomy
is rated at 60 percent regardless of number of ribs
removed.   If, at a later date, thoracoplasty becomes
necessary for obliteration of space within the thorax,
the rating for pneumonectomy shall be combined with
a rating removal of the ribs.   Note (2), which follows
code 5297 in the VASRD, provides rating guidance for
a case of that type.

E2.A1.2.20.  6816.   Lobectomy.    An entire lobe other
than the right middle lobe must be removed for the defect
to be ratable.   Excision of the right middle lobe,
segment resection, or lingulectomies are not ratable.
  Ratings are based on total body impairment.

E2.A1.2.21.  6847.   Sleep Apnea Syndromes.    The VASRD
lists four percentage rating options:   0%, 30%, 50%,
and 100% under this code, corresponding to assessed
levels of disability relative to civilian earning capacity
due to Sleep Apnea.   The following interpretation will
apply:

Total industrial impairment

100%

Considerable industrial impairment

  50%

Definite industrial impairment

  30%

Mild industrial impairment

    0%

E2.A1.3.  7000 Series Codes 

E2.A1.3.1.  7000 Series.   Cardiovascular Disease. 
  (Tables 3 and 3a provide guidance for rating cardiac
functional status.)

E2.A1.3.1.1.  Pyramiding Must be Avoided.    Only one
rating should be given for all manifestations of cardiovascular
or renal disease when, according to accepted medical
principles, the conditions have the same origin or cause.
  For example, hypertension and end organ nephropathy
due to arteriosclerosis are related etiologically and
may be regarded as one clinical entity.   The disability
should be rated under the code representing the predominant
signs and symptoms.   In some cases, the related manifestations
in another body system will be so severe as to increase
the Service member's overall impairment to the point
that the next higher percentage under the selected code
shall be justified.   The note in the VASRD under code
7507 is pertinent.

E2.A1.3.1.2.  Criteria for Assigning Ratings Under These
Codes are: 

E2.A1.3.1.2.1.  The 100 percent rating.   When more
than sedentary employment is precluded.   New York Heart
Association Functional Therapeutic Class IV (NYHA FTC
IV).

E2.A1.3.1.2.2.  The 60 percent rating.   When more than
light manual labor is precluded as indicated by a NYHA
FTC III heart or by congestive heart failure as established
by a left ventricular ejection fraction reading in the
low 20's.

E2.A1.3.1.2.3.  The 30 percent rating.   When more than
ordinary manual labor is prevented, for instance, by
NYHA FTC IIb heart.

E2.A1.3.1.3.  Types of employment referred to, above,
and used for rating purposes are:

E2.A1.3.1.3.1.  Sedentary Employment.    Work that is
not time dependent.

E2.A1.3.1.3.2.  Light Manual Labor.    “Bench work”
equivalents.

E2.A1.3.1.3.3.  Ordinary Manual Labor.    Leg, back,
and arm effort; time dependent.

E2.A1.3.1.3.4.  Strenuous Labor.    Repetitive and rapid
combined arm, leg and trunk effort.

E2.A1.3.1.4.  Valvular Heart Disease.    Valvular heart
disease not of arteriosclerotic or hypertensive origin
should be rated as rheumatic heart disease, code 7000
if the predominant symptoms are due to valvular pathology.

E2.A1.3.1.5.  Rheumatic Heart Disease 

E2.A1.3.1.5.1.  A determination of existed prior to
service for rheumatic heart disease may be justified
even though its presence was not previously recorded.
  Such a determination shall depend upon the medical
history and findings in the light of accepted medical
principles.   A stenotic valvular lesion, discovered
early in military service, is an example.

E2.A1.3.1.5.2.  A "definitely" enlarged heart is one
in which there is positive evidence of enlargement beyond
the "doubtful" or "borderline" enlargement that is sometimes
reported when the presence of enlargement is uncertain.
  Voltage criteria alone are not acceptable as electrocardiographic
evidence of definite enlargement.   Enlargement of the
heart shall be determined by objective evidence using
appropriate measures other the electrocardiogram.

E2.A1.3.1.5.3.  The 100 percent rating for active rheumatic
heart disease for 6 months is not applicable.

E2.A1.3.2.  7005-7017.   Disease of the Coronary Arteries,
Surgical Procedures, and Trauma 

E2.A1.3.2.1.  For Service members on active duty, to
include those active duty for less than 31 days, myocardial
infarction incurred during such periods shall be presumed
“aggravated” by performing such duty.   This presumption
may be overcome when it can be shown by a preponderance
of evidence that the condition was not aggravated by
military service.

E2.A1.3.2.2.  Coronary bypass surgery, valve prosthesis,
or other cardiac surgery shall be rated on the extent
of residual functional impairment when the condition
is stable.   If stability cannot be established, a period
of TDRL should be considered.

E2.A1.3.2.3.  7015-7017; 7110.   Surgical Procedures
Associated with AV Block, Heart Valve Replacement, Aneurysms.
   Convalescent ratings and ratings for specified periods
of time following surgery do not apply.   Ratings are
based on the degree of functional impairment.   However,
maximum ratings do apply.

E2.A1.3.2.4.  7100.   Arteriosclerosis, general.   
The 20 percent rating under that code is rarely appropriate.
  It is preferable to rate impairment of the body system
most involved by the disease.

E2.A1.3.2.5.  7114-7117.   Peripheral Vascular Diseases


E2.A1.3.2.5.1.  The symptoms and signs of these conditions
should be considered as manifestations of a systemic
disease entity, wherein bilateral involvement of extremities
is natural and expected.   They are distinct from local
mechanisms affecting peripheral circulation (for example,
varicose veins or phlebitis) in which bilateral involvement
is more nearly equivalent to coincidental duplication
of the disease, rather than its direct extension.

E2.A1.3.2.5.2.  When manifestations are limited to the
extremities, the percentage of disability is based on
the most severely affected extremity unless each of
the two or more extremities separately meets the requirements
for valuation in excess of 20 percent.   In the latter
case, 10 percent shall be added to (not combined with)
the valuation for the more severely affected extremity,
except where the disease has resulted in amputation.
  When both upper and lower extremities are involved,
the above rating procedures are first applied to the
upper extremities, then to the lower extremities.  
Ratings shall be combined if each group has a total
rating in excess of 20 percent.

E2.A1.3.2.5.3.  The bilateral factor applies in all
cases of an amputation of one extremity with any compensable
degree of disability of the other extremity.

E2.A1.3.2.5.4.  A rating of 20 percent or less for a
peripheral vascular disease should not be combined with
any other peripheral vascular disease rating.

E2.A1.3.2.5.5.  Peripheral vascular disease ratings
for codes 7114 through 7117 are listed in table 4.

E2.A1.3.2.6.  7120 (7199-7120).   Hypercoagulable states
requiring chronic anticoagulation 

E2.A1.3.2.6.1.  A minimum rating of 30 percent is given
if there have been episodes of thrombophlebitis or emboli
in the past year.

E2.A1.3.2.6.2.  A zero percent rating is given if there
have been no episodes of thrombophlebitis or embolus
in the past year.

E2.A1.3.2.6.3.  Higher ratings are based on residuals
to emboli or thrombophlebitis.

E2.A1.3.2.7.  7305.   Ulcer, Duodenal.    Medical and
surgical management have been increasingly effective.
  Cases refractory to accepted medical therapy may be
determined unfit for continued active duty.

E2.A1.3.2.8.  7307.   Gastritis, Hypertrophic.    That
diagnosis must be made by endoscopy.   It should not
be rated separately, however, if other conditions are
present that produce a common impairment.   A single
valuation shall be assigned under the diagnostic code
that reflects the predominant disability with elevation
to the next higher rating if the severity of the overall
disability warrants.

E2.A1.3.2.9.  7308.   Postgastrectomy Syndrome.    In
evaluating and rating, care must be taken to differentiate
between nondisabling symptoms or minor discomfort which
sometimes result from overindulgence, such as that experienced
from overeating by a person without a gastrectomy, and
discomfort symptomatic of a true postgastrectomy syndrome.
  Circulatory or comparable symptoms, even though mild
or intermittent, such as a need for rest after meals,
are indicative of impairment that may be a basis for
rating.

E2.A1.3.2.10.  7328-7329.   Intestinal Resections. 
  When portions of both large and small intestines have
been removed, the rating should be done using the code
that is most representative of the clinical manifestations.

E2.A1.3.2.11.  7332-7336.   Ano-Rectal Conditions. 
  Pilonidal cyst or sinus is primarily a disorder of
ectoderm and shall be rated as a skin condition.   However,
when an active process is present the rating is by analogy
to Code 5000.

E2.A1.3.2.12.  7338.   Hernia, Inguinal.    If correctable
and there are not contra-indications to surgery, hernia
is not ratable even if surgery if refused.

E2.A1.3.2.13.  7345.   Hepatitis, Infectious 

E2.A1.3.2.13.1.  Acute infectious hepatitis will usually
resolve without residual impairment.   Liver function
tests should return to normal.

E2.A1.3.2.13.2.  Chronic persistent hepatitis is a condition
with minimally disturbed histology and liver function
tests.   There is no persistent disability or progression,
and both time and supporting evidence confirm that.
  Rating for residuals is seldom justified.   Placement
on the TDRL may be proper when the clinical and laboratory
course (particularly in the presence of persistent antigenemia)
indicates a need for continued observation to rule out
chronic active hepatitis.

E2.A1.3.2.13.3.  Chronic active hepatitis is a frequently
progressive condition that may or may not be associated
with a demonstrable antigen.   Since the course of the
disease is often difficult to predict, placement on
the TDRL may be proper before permanent disposition
is made.

E2.A1.3.2.14.  7347.   Pancreatitis.    If diabetes
is present, the predominant disease should be rated,
with consideration given to the other, under a single
code, to avoid pyramiding.

E2.A1.3.2.15.  7500-7542.   The Genitourinary System


E2.A1.3.2.15.1.  The VASRD has published a new rating
scheme for disabilities related to the genitourinary
system based on renal or voiding dysfunctions, infections,
or a combination of these.   The major areas of rating
are as follows:

E2.A1.3.2.15.1.1.  Renal dysfunction

E2.A1.3.2.15.1.2.  Voiding dysfunction

E2.A1.3.2.15.1.2.1.  Urinary frequency

E2.A1.3.2.15.1.2.2.  Obstructed voiding

E2.A1.3.2.15.1.3.  Urinary tract infection

E2.A1.3.2.15.2.  7500-7531.   The Genitourinary System.
   Sterility and impotence are not ratable entities.
  Anatomical loss of procreative organs shall not be
rated.

E2.A1.3.2.15.3.  7500-7509.   Upper urinary tract. 
  In assessing impairment of the upper urinary tract,
the endogenous creatinine clearance tests serve as guidelines
for evaluating renal function.   Normal creatinine clearance
is 80-139 milliliters (ml)/minute in men and 80-125
ml/minute in women.   (See Table 5).

E2.A1.3.2.15.4.  7512.   Total Incontinence.    Incontinence
may be rated as bladder fistula, 100 percent, when use
of an appliance is unsatisfactory or not feasible.

E2.A1.3.2.15.5.  7526.   Prostate Resection.    In order
to be ratable, there must be symptoms and objective
evidence of impairment.

E2.A1.3.2.15.6.  7528.   New growths, Malignant, Any
Specified Part of Genitourinary System.    Some malignant
tumors of the genitourinary tract are subject to cure,
even if widespread metastases have taken place.   Completion
of treatment and follow-up on active duty are desirable.
  If adverse reaction to treatment or persistent evidence
of tumor activity interfere with duty, TDRL may be considered.
  In those instances when specific tumors are refractory
to all treatment, final disposition should be made.

E2.A1.3.2.15.7.  7542.   Neurogenic Bladder.    The
number of required catheterizations or number of changes
of absorbent pads per day should be listed to ascertain
the functional impairment.

E2.A1.3.2.16.  7600-7627.   Gynecological Conditions


E2.A1.3.2.16.1.  The VASRD has rating criteria for unfitting
gynecological conditions that include endometriosis
and removal of the mammary gland(s) or segments of the
mammary gland.

E2.A1.3.2.16.2.  7617, 7618, 7619.   Procreative Organs.
   Loss of procreative organs is not ratable.   Only
significant disqualifying residuals should be rated.

E2.A1.3.2.16.3.  7626-7627.   Mammary Gland Removal.
   Not all Service members who have had mastectomies
for malignancy are unfit.   Unfitness is based on residual
impairment of the arm or chest wall or effects of radiation
or other treatment.   The 100 percent rating in the
VASRD does not apply in cases in which the Service member
does not have evidence of metastasis.

E2.A1.3.2.17.  7703.   Leukemia.    Leukemia requiring
the use of chemotherapeutic agents is rated analogous
to leukemia requiring irradiation or transfusion.  
Although some prolonged remissions and "cures" are being
achieved with acute leukemia, temporary retirement should
be considered in most cases at a maximum rating.   Service
members with chronic leukemia who require treatment
are often fit for prolonged periods of time with few
profile restrictions.   Such cases must be individually
judged on their merits.   The principles noted below
under 7709, paragraph (E2.A1.3.2.19.2.), should be considered
in leukemia cases.

E2.A1.3.2.18.  7705-7706.   Purpura Hemorrhagica; Splenectomy.
   Only residuals, if any, of the basic condition leading
to the splenectomy should be rated.

E2.A1.3.2.19.  7709.   Lymphogranulomatosis (Hodgkin’s
Disease) 

E2.A1.3.2.19.1.  Clinical staging serves as a general
guide for treatment, rating, and disposition of Hodgkin’s
Disease.   Table 6 can be used with the understanding
that many advances in treatment that may permit exceptions
are taking place.

E2.A1.3.2.19.2.  Prolonged remissions and cures, even
with salvage treatment, are becoming more commonplace.
  Regardless of the pretreatment stage of the disease,
retention on active duty during treatment, or return
to active duty after treatment on the TDRL may be possible.
  Intensive treatment, however, may be extremely traumatic.
  Degradation of both physical and mental functions
may be disabling for varying periods of time.   Final
disposition must be individualized according to both
subjective and objective residuals.

E2.A1.3.2.20.  7714.   Sickle Cell Anemia.    The VASRD
rates all the manifestations of sickle cell disease
and its variants.   Individuals with the more severe
hemoglobinopathies are not acceptable for entry into
the Military Services.   Policies concerning line of
duty and Service aggravation apply.

E2.A1.3.2.21.  7716.   Aplastic Anemia.    That is a
new ratable condition.   A Service member scheduled
for transplantation shall be rated after the transplant.

E2.A1.3.2.22.  7801-7802.   Scars, Burns.    When calculating
burn areas, Plate IV,  Table 7 and the following measurements
may be of assistance:

Average 70kg (150 lbs) male body surface

=

1.7m2

2636 in2

=

18.3 ft2

1 meter

=

39.375 inches

1 meter2

=

1550.4 in2

E2.A1.3.2.23.  7913.   Diabetes Mellitus 

E2.A1.3.2.23.1.  The format published by the National
Diabetes Group shall serve as the basis for classifying
diabetes mellitus (DM).   The severity of each case
should be individualized taking into consideration the
expected natural course of the disease variants.   Insulin
dosage is not a good indicator of severity and is only
one factor to consider in the overall evaluation of
the disease.   Response to specific therapy, diet, activity,
compliance, and time are all important.   With adequate
compliance, many diabetics are fit with minimum restrictions.
  That is particularly true of type II DM (noninsulin
dependent), even though insulin is prescribed for optimum
control.   Young adults with type I DM (insulin dependent)
are not a good risk for retention.

E2.A1.3.2.23.2.  If unfitness derives, in part, from
documented non-compliance with prescribed treatment,
including diet and weight control, the assigned rating
should not be higher than the disease would warrant
if under prescribed treatment.

E2.A1.3.2.23.3.  DM controlled by diet and oral medication,
without a need for daily insulin, and that does not
impair health or vigor, or cause significant limitation
of activity, is considered to be mild, if unfitting.

E2.A1.3.2.23.4.  Ratings must reflect the severity of
the DM, as such. Undue importance should not be given
to early or questionable complications.   That is particularly
true in considering ratings of 60 percent or above.
  In most instances, a lower rating should be given.
  Complications such as vascular insufficiency, visual
defects, pruritis, and neuropathies should be rated
separately.   The presence of early or questionable
complications in otherwise less than severe DM does
not automatically warrant a higher rating.

E2.A1.4.  8000 Series Codes 

E2.A1.4.1.  8000-8412.   Organic Disease of the Central
Nervous System 

E2.A1.4.1.1.  Careful correlation of the footnote under
8046 with the italicized introduction to 8000-8046 should
enable Boards to select the proper rating approach.
  In some of those conditions, the minimum rating may
be awarded on the basis of the diagnosis alone, whether
or not there are residuals.   In others, the minimum
rating may be awarded only if there are residuals. 
 If such cases have neither residuals capable of objective
verification nor subjective residuals which are credible,
consistent with the disease, and are not more likely
attributable to other disease, the condition should
be ratable at zero percent, if the Service member is
unfit.

E2.A1.4.1.2.  8007-8009.   Brain Vessels.    The six-month
convalescent rating does not apply.   In many of these
cases, the danger of disastrous recurrences justifies
a rating (of residuals) sufficiently liberal to provide
temporary retirement and subsequent re-evaluation.

E2.A1.4.1.3.  8017-8018, 8023-8025.   Degenerative Disorders
of the Central Nervous System.    Combined ratings may
be assigned under those codes with the bilateral factor
added.

E2.A1.4.1.4.  8100.   Migraine.    "Prostrating" means
that the Service member must stop what he or she is
doing and seek medical attention.   The number of prostrating
attacks per time period (day, week, month) should be
recorded by a neurologist for diagnostic confirmation.
  Estimation of the social and industrial impairment
due to migranious attacks should be made.

E2.A1.4.1.5.  8108.   Narcolepsy.    The VASRD defers
the determination of disability ratings to code 8911
(epilepsy, petit mal).   The latter code lists five
percentage rating options for minor seizures:   10%,
20%, 40%, 60%, and 80% corresponding to assessed levels
of disability relative to civilian earning capacity
due to subject condition.   The following interpretation
will apply:

Profound industrial impairment

80%

Severe industrial impairment

60%

Considerable industrial impairment

40%

Definite industrial impairment

20%

Mild industrial impairment

10%

E2.A1.4.1.6.  8205-8412.   Diseases of the Cranial Nerves.
   There is provision for combined ratings under these
codes when there is bilateral involvement, but without
the addition of the bilateral factor.

E2.A1.4.2.  8510-8730.   Disease of the Peripheral Nerves


E2.A1.4.2.1.  Cases that are rated based on residuals
should be adjudicated on the basis of impairment of
function rather than on anatomical diagnosis.   For
example, a complete paralysis of the circumflex nerve
of the major extremity carries a 50 percent rating under
8518.   In many cases, however, abduction of the arm
when the circumflex nerve is paralyzed is possible because
other muscles take over the function of the paralyzed
muscles.   To warrant the 50 percent rating, the Service
member's residual loss of function must actually include
all the defects listed under 8518.   When other muscles
have taken over the function of the circumflex-innervated
deltoid, the residual loss of function is properly ratable
under 5201, “limitation of arm motion”, or 5303, “muscle
injury, Group III”, whichever better reflects the predominant
impairment.   Careful documentation of evaluations are
required before assigning a rating for paralysis that
would equal that for amputation of the innervated area.
  For example, cases of “paralysis of the common peroneal
nerve with foot drop”, 8521, should be rated in terms
of loss of function. “Amputation below the knee”, 5165,
is ratable at 40 percent.   In order to warrant a similar
rating for peroneal palsies, there must be sufficiently
severe symptoms, such as trophic and circulatory changes
and other concomitants, to make the functional impairment
reasonably equivalent to loss of foot.

E2.A1.4.2.2.  Service members with paralysis of an extremity
or hemiparesis shall be rated according to the Table
of Analogous Ratings. Codes are as follows:

E2.A1.4.2.2.1.  8599 - 8513 - Paralysis of upper extremity

E2.A1.4.2.2.2.  8599 - 8520 - 8526 - Paralysis of lower
extremity

E2.A1.4.2.3.  8599.   Scalenus Anticus Syndrome.   
That syndrome is rated by analogy with the lower radicular
group (8512), or less commonly, with either erythromelalgia
(7119) or Raynaud’s Disease (7117), depending upon predominant
symptoms and overall functional impairment.

E2.A1.4.3.  8910-8914.   Epilepsies 

E2.A1.4.3.1.  Service member must be evaluated and the
diagnosis made by a neurologist.

E2.A1.4.3.2.  The number of seizures each time frame
(day, week, and month) must be recorded.

E2.A1.4.3.3.  Attacks following omission of prescribed
medication or the ingestion of alcoholic beverages are
not indicative of the controllability of the disease
and are not relevant to the determination of seizure
frequency for rating purposes.

E2.A1.4.3.4.  Estimation of the social and industrial
impairment due to the seizure activity should be made.

E2.A1.4.3.5.  Seizures that occur during sleep ("nocturnal
seizure") are not relevant to the determination of seizure
frequency unless they can be shown to significantly
impair industrial adaptability.

E2.A1.5.  9000 Series Codes 

E2.A1.5.1.  9200-9511. Mental Disorders 

E2.A1.5.1.1.  Functional Impairment.    Loss of function
is the principal criterion for establishing the level
of impairment resulting from mental illness.   Loss
of function is reflected in impaired social and industrial
adaptability.   Psychoses specifically include disorders
manifesting disturbances of perception, thinking, emotional
control, and behavior, severe enough to hinder economic
adjustment, that is, hinder the Service member's capacity
to perform military duties or to earn a living.   Even
psychosis, however, may resolve such that the impact
on economic adjustment is minimal to none.

E2.A1.5.1.1.1.  In rating impairment of social and industrial
capability, if any, a comparison must be made between
pre- and post-illness adjustment.   All pertinent information
provided by the MEB and TDRL interim examination done
by the examining physicians and other competent medical
authorities should be reviewed before arriving at a
final determination.   Inconsistencies between the clinical
data (history, mental status, hospital course, and present
condition) and the diagnosed psychiatric condition,
or between data provided by different physicians must
be resolved before a final rating decision.   Action
taken to resolve these difference should be documented
in the proceedings.

E2.A1.5.1.1.2.  Assessing the degree of permanent impairment
resulting from a psychotic process is often difficult
during the weeks immediately following an acute episode.
  Sometimes a Service member's period of intensive in-hospital
treatment has not been completed at the time of the
initial MEB.   With the passage of time, the clinical
picture often becomes stable.   The degree of permanent
impairment may then be estimated more accurately.

E2.A1.5.1.2.  Social impairment.    Information that
relates to social impairment includes, but is not limited
to, the following:

E2.A1.5.1.2.1.  Living arrangements (by oneself, with
parents and siblings, or with wife and children).

E2.A1.5.1.2.2.  Marital status (single, married, separated,
or divorced, and the type of relationship (harmony or
strife)).

E2.A1.5.1.2.3.  Leisure activity (sports, hobbies, TV,
reading, sleeping).

E2.A1.5.1.2.4.  Acquaintances (male, female, both sexes,
many, few).

E2.A1.5.1.2.5.  Substance use or abuse (alcohol and/or
illicit drugs).

E2.A1.5.1.2.6.  Police record.

E2.A1.5.1.3.  Industrial Impairment.    Information
that relates to industrial impairment includes, but
is not limited to, the following:

E2.A1.5.1.3.1.  Job stability (unemployed, part-time
work, full-time job, quit, fired, or promoted).

E2.A1.5.1.3.2.  Type of job (menial, responsible, OJT,
technical, for a relative, or for a private employer).

E2.A1.5.1.3.3.  Schooling (grade, technical, academic,
high school, college, or postgraduate).

E2.A1.5.1.4.  Additional Factors.    Other factors that
bear on social and industrial adaptability include,
but are not limited to, the following:

E2.A1.5.1.4.1.  Mental Competency.    The MEB should
include a statement as to whether the Service member
is competent to handle his or her financial affairs,
and to participate in Board proceedings.

E2.A1.5.1.4.2.  Level of Supervision.    There are several
levels of supervision.   The most disabling is constant
hospitalization.   Constant supervision at home or intermittent
and repeated hospitalizations are disabling factors
to be considered.   Being placed in one's own custody
suggests that a lower level of supervision, if any,
is required.

E2.A1.5.1.4.3.  Contact with Reality.    Certain Service
members have lost all contact with reality and cannot
tell fact from fantasy.   Dreams, imaginations, delusions,
and hallucinations are just as real to certain Service
member as actual events.   The quality of loss of contact
with reality as well as quantity of time that the Service
member is not in contact with reality are factors to
be considered.

E2.A1.5.1.4.4.  Potential for Harm.    At times, individuals
suffering from mental disorders may be dangerous to
themselves or to others.   They may be homicidal, suicidal,
or violently destructive to property.   Their judgment
may be so impaired that they could jeopardize or destroy
a family, business, or themselves, financially, socially,
and legally.

E2.A1.5.1.4.5.  The degree of industrial and industrially
related social impairment is influenced by the number
and intensity of signs or symptoms of mental disorders.
  Those signs or symptoms may be overtly apparent or
they may be subtle and apparent only to skilled examiners.
  Their significance must be carefully evaluated.  
A partial list of the more common signs or symptoms
include autism, ambivalence, inappropriate affect, dissociative
thinking, bizarre behavior, delusions, hallucinations,
pronounced anxiety, hyperactivity, depression, disorientation,
emotional lability, memory defects, unfounded somatic
complaints, phobias, compulsions, lack of insight, and
poor judgment.

E2.A1.5.1.4.6.  Medication or Psychotherapy.    The
type of (potent or mild), the amount (large or small
doses) and the route of administrations of medication
as well as the frequency (daily, weekly, or as needed)
should be considered.   The frequency of psychotherapy
and by whom administered (psychiatrist, psychologist,
social worker, nurse) also should be considered.   The
fact that a Service member is receiving medication and/or
psychotherapy does not automatically equate with a certain
level of disability.

E2.A1.5.1.5.  VASRD Classification.    The VASRD uses
specific terms to classify the level of social and industrial
impairment.   Those are further characterized below
for ratings under 9201 through 9511.

E2.A1.5.1.5.1.  Total at 100 percent.

E2.A1.5.1.5.1.1.  Usually mentally incompetent to handle
financial affairs and to participate in PEB proceedings.

E2.A1.5.1.5.1.2.  Usually hospitalized; rarely in care
of next of kin or guardian.

E2.A1.5.1.5.1.3.  Actively psychotic, and often totally
out of contact with reality.

E2.A1.5.1.5.1.4.  Requires constant supervision and
care.

E2.A1.5.1.5.1.5.  Significant potential to be harmful
to self or others.

E2.A1.5.1.5.1.6.  Employability limited to sheltered
supervised settings.

E2.A1.5.1.5.1.7.  Incapable of any social adjustment.

E2.A1.5.1.5.2.  Severe at 70 percent.

E2.A1.5.1.5.2.1.  Usually financially mentally competent
and capable of cooperating in PEB proceedings but occasionally
may be incompetent.

E2.A1.5.1.5.2.2.  Usually hospitalized, but often in
care of next of kin or guardian.

E2.A1.5.1.5.2.3.  Actively psychotic, but may have intermittent
contact with reality.

E2.A1.5.1.5.2.4.  Requires supervision approximately
50 percent or more of the time.

E2.A1.5.1.5.2.5.  Some potential to be harmful to self
or others.

E2.A1.5.1.5.2.6.  Unemployable

E2.A1.5.1.5.2.7.  Evidence of minimal social adjustment.

E2.A1.5.1.5.3.  Considerable at 50 percent.

E2.A1.5.1.5.3.1.  Nearly always mentally competent to
handle financial affairs and to participate in PEB proceedings.

E2.A1.5.1.5.3.2.  Overtly displays some signs or symptoms
of mental illness such as:   autism, ambivalence, inappropriate
affect, dissociative thinking, delusions, hallucinations,
hyperactivity, depression, lack of insight, poor judgment,
bizarre behavior, disorientation, emotional lability,
memory defects, unfounded somatic complaints, phobias,
compulsions, decreasing IQ, and personality changes.

E2.A1.5.1.5.3.3.  Requires constant medications or psychotherapy.

E2.A1.5.1.5.3.4.  Suffers extreme job instability (not
due to substance abuse, economic conditions, personality
disorders, etc.).

E2.A1.5.1.5.3.5.  Suffers significant industrially related
social maladjustment (not due to substance abuse, economic
conditions, personality disorders, etc.).

E2.A1.5.1.5.3.6.  May demonstrate a significant requirement
for hospitalization.

E2.A1.5.1.4.4.  Definite at 30 percent.

E2.A1.5.1.4.4.1.  Does not demonstrate a significant
requirement for hospitalization.

E2.A1.5.1.4.4.2.  Displays some signs or symptoms of
mental illness on examination.

E2.A1.5.1.4.4.3.  Usually requires medication and/or
frequent psychotherapy.

E2.A1.5.1.4.4.4.  May experience some job instability.

E2.A1.5.1.4.4.5.  Evidences borderline social adjustment.

E2.A1.5.1.4.5.  Mild at 10 percent

E2.A1.5.1.4.5.1.  Maintains an adequate job adjustment.

E2.A1.5.1.4.5.2.  Maintains an adequate social adjustment.

E2.A1.5.1.4.6.  Full remission at zero percent.

E2.A1.5.1.4.6.1.  Symptom free.

E2.A1.5.1.4.6.2.  Requires only interval medical supervision.

E2.A1.5.1.4.6.3.  Has an acceptable work record, if
employed.

   

Table 8 has been compiled to assist in the determination
of functional impairment.   Terminology is consistent
with the “Diagnostic and Statistical Manual of Mental
Disorders IV”.   It is viewed as an aid rather than
a prescription.

TABLE 1

 GRADE VALUE TABLE 

A

Individual Finger Defect

B

Rated As

C

Grade Value

Amputation through distal phalanx or distal joint (except
the thumb) other than negligible tip loss.

Favorable ankylosis (See VASRD, note c following code
5151)

    1

Amputation through middle phalanx or distal phalanx
of thumb.

Unfavorable ankylosis (See VASRD, note b following code
5151)

    2

Amputation though proximal phalanx or proximal interphalangeal
joint.

Amputation (See VASRD, note a following code 5151)

    3

Amputation of entire digit, with amputation or resection
of more than one-half of the metacarpal.

Single finger amputation with metacarpal resection (See
VASRD, codes 5152-5156)

    4

TABLE 2

PULMONARY FUNCTION TEST VALUES 1

 1The AMA "Guides to the Evaluation of Permanent Impairment,"
while

differing slightly from the above values, is otherwise
helpful in

interpreting clinical and functional values.   There
are no FEV-1 

Percentage or VC Percentage between 51 and 54.

(FEV-1)

Forced Expiratory Volume (FEV-1)

Rating

(Percentage of predicted)

Chronic Obstructive Pulmonary Disease

(Before Bronchodilators)

50 or less

Severe

55-65

Moderate, moderately severe

65-70

Mild

70 or better

Normal

Vital Capacity (VC)

(Percentage of predicted)

Rating

Chronic Restrictive Pulmonary Disease

50 or less

Severe

55-65

Moderate, moderately severe

65-80

Mild

80 or better

Normal

TABLE 3

METHODS OF ASSESSING CARDIOVASCULAR DISABILITY

New York Heart

Association Functional

Class Classification

Canadian Cardiovascular

Society Functional

Classification

Specific Activity Scale

(Goldstein et al:

Circulation 64:1227; 1981

and Science of American

Medicine I: 15-16)

New York Heart

Association Functional

Class Classification

(Revised)

I. Patient with cardiac disease, but without resulting
limitations of physical activity.   Ordinary physical
activity does not cause undue fatigue, palpitations,
dyspea, or anginal pain.

Ordinary physical activity, such as walking or climbing,
does not cause angina.   Angina with rapid or strenuous
or prolonged exertion at work or recreation.

Patients can perform to completion any activity requiring
7 metabolic equivalent:   e.g., can carry 24 lbs up
eight steps, carry objects that weigh 80 lbs, do outdoor
work (shovel snow or spade soil), do recreational activities
(skiing, basketball, squash, handball , jog and walk
5 MPH).   (See table 3A, Approximate Metabolic Cost
of Activities)

Cardiac status uncompromised.

II. Patients with cardiac disease resulting in slight
limitation of physical activity. They are comfortable
at rest.   Ordinary physical activity results in fatigue,
palpitation, dyspnea, and anginal pain.

Slight limitation of ordinary activity.   Walking or
climbing stairs rapidly, walking uphill, walking or
stair climbing after meals, in cold, in wind, or under
emotional stress, or during the few hours after awakening.
  Walking more than two blocks and climbing more than
one flight of stairs at normal pace under normal conditions.

Patient can perform completion of any activity requiring
> 5 metabolic equivalents, but cannot and does not perform
to completion activities requiring metabolic equivalents:
e.g., have sexual intercourse without stopping, garden,
rake, weed, roller skate, dance, fox trot, walk at 4
MPH on level ground.   (See table 3A, Approximate Metabolic
Cost of Activities).

Cardiac status slightly compromised

III. Patient with cardiac disease resulting in marked
limitation of physical activity.   They are comfortable
at rest.   Less than ordinary physical activity causes
fatigue, palpitation, dysnea, or anginal pain.

Marked limitation of ordinary physical activity.   Walking
one to two blocks on the level and climbing more than
one flight in normal conditions.

Patients can perform to completion any activity requiring
> 2 metabolic equivalents but cannot and does not perform
to completion any activities requiring > 5 metabolic
equivalents: e.g., shower without stopping, strip and
make bed, clean windows, walk 2.5 MPH, bowl, golf, dress
without stopping.   (See table 3A, Approximate Metabolic
Cost of Activities)

Cardiac status moderately compromised

TABLE 3, continued

METHODS OF ASSESSING CARDIOVASCULAR DISABILITY, continued

New York Heart

Association Functional

Class Classification

Canadian Cardiovascular

Society Functional

Classification

Specific Activity Scale

(Goldstein et al:

Circulation 64:1227; 1981

and Science of American

Medicine I: 15-16)

New York Heart

Association Functional

Class Classification

(Revised)

IV. Patients with cardiac disease resulting in inability
to carry on any physical activity without discomfort.
  Symptoms of cardiac insufficiently or of the anginal
syndrome may be present even at rest.   If any physical
activity is undertaken, discomfort is increased.

Inability to carry on any physical activity without
discomfort -- anginal syndrome may be present at rest.

Patient cannot and does not perform to completion activities
requiring < 2 metabolic equivalents.   Cannot carry
out activities listed above (specific activity scale,
Class III).   (See Table 3A, Approximate Metabolic Cost
of Activities)

Severely compromised

NEW YORK HEART ASSOCIATION THERAPEUTIC CLASSIFICATION

Revised Classification

Therapeutic Classification

(Prognosis)

Class A -- Patients with cardiac disease whose physical
activity need not be restricted.

Class I - Good

Class B -- Patients with cardiac disease whose ordinary
physical activity need not be restricted, but who should
be advised against severe or competitive physical efforts.

Class II - Good with therapy.

Class C -- Patients with cardiac disease whose ordinary
physical activity should be moderately restricted, and
whose strenuous efforts should be discontinued.

Class III - Fair with therapy.

Class D -- Patients with cardiac disease whose ordinary
physical activity should be markedly restricted.

Class IV - Guarded despite therapy.

Class E -- Patients with cardiac disease who should
be at complete rest, confined to bed or chair.

TABLE 3A

APPROXIMATE METABOLIC COST OF ACTIVITIES (Source: American
Heart Association)

Energy Expenditure

Occupational

Recreational

1.5 - 2 METs  1

     4-7 ml O2/kg/min;

     2-2.5 kcal/min (70 kg person)

Desk work

Driving an automobile 2

Typing (electric)

Electric calculating machine

     operation.

Standing

Walking (strolling 2.6 km or 1 mph)

Piloting a plane  2, motorcycling 2

Playing cards 2

Sewing, knitting

2-3 METs

     7-11 ml O2/kg/min;

     2.5-4 kcal/min (70 kg person)

Auto Repair

Radio/TV work

Janitorial work

Typing (manual) 

Bartending

Level walking (3.25 km or 2 mph)

Level bicycling (8 km or 5 mph)

Riding lawn mowers

Billiards, bowling

Skeet  2, shuffleboard

Woodworking (light) 

Driving a powerboat 2

Golf (using power cart) 

Canoeing (4 km or 2.5 mph) 

Horseback (walk)

Playing various musical instruments

3-4 METs

     11-14 ml O2/kg/min;

     4-5 kcal/min (70 kg person)

Brick laying, plastering

Pushing a wheelbarrow

     (45 kg or 100 lb load)

Machine assembly

Driving a tractor trailer in traffic

Welding (moderate load)

Cleaning windows

Walking (5 km or 3 mph)

Cycling (10 km or 6 mph)

Horseshoe pitching

Volleyball (6 man, competitive)

Golf (pulling bag cart)

Archery

Sailing (handling small boat)

Fly fishing (standing in waders)

Horseback (sitting while trotting)

Badminton (social doubles)

Pushing light power mower

Energetically playing various music

     instruments

4-5 METs

     14-18 ml O2/kg/min;

     5-6 kcal/min (70 kg person)

Painting

Masonry

Paperhanging

Light carpentry

Walking (5.5 km or 3.5 mph)

Cycling (13 km or 8 mph)

Table tennis

Golf (carrying bag)

Dancing (fox trot) 

Badminton (singles)

Tennis (doubles)

Raking leaves, hoeing

Various calisthenics

5 - 6 METs  1

     18-21 ml O2/kg/min;

     6-7 kcal/min (70 kg person)

Digging in garden

Shoveling light earth

Walking (6.5 km or 4 mph)

Cycling (16 km or 10 mph)

Canoeing (6.5 km or 4 mph) 

Horseback riding (posting while

     trotting)

Stream fishing (walking in light

     current with waders) 

Ice or roller skating (15 km or

     9 mph)

TABLE 3A, continued

APPROXIMATE METABOLIC COST OF ACTIVITIES, (Source: American
Heart Association)

Energy Expenditure

Occupational

Recreational

 1One MET = energy expenditure at rest equivalent to
approximately 3.5 mi O2/kg

body weight/minute.

 2A major excess metabolic increase may occur owing
to excitement, anxiety, or 

impatience in some of these activities.   A physician
must assess the patient’s 

physiologic reactivity.

6-7 METs

     21-25 ml O2/kg/min; 

     7-8 kcal/min (70 kg person)

Shoveling 10/min

     (4.5 kg or 10 lb)

Walking (8 km or 5 mph) 

Cycling (17.5 km or 11 mph) 

Badminton (competitive) 

Tennis (singles) 

Splitting wood

Snow shoveling

Hand lawn mowing

Square dancing

Downhill skiing (light) 

Ski Touring (4 km or 2.5 mph) 

     (light snow) 

Water-skiing

7-8 METs

     25-28 ml O2/kg/min; 

     8-10 kcal/min (70 kg person)

Digging ditches

Carrying 36.3 kg or 80 lb

Sawing hardwood

Jogging (8 km or 5 mph) 

Cycling (19 km or 12 mph)

Horseback riding (gallop)

Downhill skiing (vigorous)

Basketball

Mountain climbing

Ice hockey

Canoeing (8 km or 5 mph) 

Touch football

Paddleball

8-9 METs

     28-32 ml O2/kg/min; 

     10-11 kcal/min (70 kg person)

Shoveling 10/min

     (6.4 kg or 14 lb)

Running (9 km or 5.5 mph) 

Cycling (21 km or 13 mph) 

Ski Touring (6.5 km or 4 mph) 

     (loose snow) 

Squash (social) 

Handball (social) 

Fencing

Basketball (vigorous)

> 10 METs

     > 32 ml O2/kg/min; 

     > 11 kcal/min (70 kg person)

Shoveling 10/min

     (7.3 kg or 16 lb)

Running: 6 mph = 10 METs

                7 mph = 11.5 METs

                8 mph = 13.5 METs

                9 mph = 15 METs

              10 mph = 17 METs

Ski Touring (8 km or 5+ mph) 

Handball (competitive) 

Squash (competitive)

TABLE 4

PERIPHERAL VASCULAR DISEASE RATING

Number of Extremities Involved

Rating of Extremities

Combined Rating

 1Bilateral factor applied.

One

20

20

40

40

60

60

Two (not paired, arm and leg)

20 and 20

20

40 and 20

40

40 and 40

60

60 and 20

60

60 and 40

80

60 and 60

80

Two paired (arms and/or legs)

20 and 20

20

40 and 20

40

40 and 40 1

50

60 and 20

60

60 and 40 1

70

60 and 60 1

70

Three extremities involved (paired extremities and one
other)

20 and 20 and 20

30

20 and 20 and 40

40

20 and 20 and 60

60

40 and 20 and 20

40

40 and 20 and 40

60

40 and 20 and 60

80

40 and 40 and 20

50

40 and 40 and 40

70

40 and 40 and 60

80

60 and 40 and 20

70

60 and 40 and 40

80

60 and 40 and 60

90

60 and 60 and 20

70

60 and 60 and 40

80

60 and 60 and 60

90

TABLE 4, continued

PERIPHERAL VASCULAR DISEASE RATING, continued

Number of Extremities Involved

Rating of Extremities

Combined Rating

All extremities (both paired extremities)

20 and 20, 20 and 20

20

40 and 20, 20 and 20

40

60 and 20, 20 and 20

60

40 and 40, 20 and 20

50

40 and 20, 40 and 20

60

40 and 40, 40 and 20

70

40 and 40, 40 and 40

80

60 and 40, 40 and 40

90

60 and 40, 60 and 40

90

60 and 60, 40 and 40

90

60 and 60, 60 and 40

90

60 and 60, 60 and 60

90

TABLE 5

CREATININE CLEARANCE AND RENAL IMPAIRMENT

Creatinine Clearance

Impairment

Less than 28 ml/minute

Severe (pronounced nephritis)

28-52 ml/minute

Moderate (moderate nephritis)

52-80 ml/minute

Mild (mild nephritis)

TABLE 6

HODGKIN'S DISEASE

(Stage A)

(Stage B)

Disposition

Stage

Rating

Rating

(if unfit) 1

 1 - Fitness or unfitness is not determined, as a rule,
until response to initial 

treatment has been assessed.

 2 - TDRL may be considered as an exception when there
has been a prompt, 

complete remission during the initial treatment phase.

I

         30

         60

                 TDRL

II

         30

         60

                 TDRL

III

         60

         - -

                 TDRL

III

         - -

         100

                 PDRL

IV

         100

         100

                 PDRL 2

TABLE 7

BODY SURFACE AREA MEASUREMENTS

           Area           

Percentage

Body Surface                     

Body Surface

Sq Inches

Sq Feet

Anterior or posterior head

       3.5

       92

   0.64

Anterior or posterior neck

       1.0

       26

   0.18

Anterior or posterior trunk

     13.0

     343

   2.28

Anterior or posterior arm

       2.0

       53

   0.37

Anterior or posterior forearm

       1.5

       40

   0.27

Valar or palmar hand and fingers

       1.25

       33

   0.23

Buttocks

       2.5

       66

   0.46

Genitalia

       1.0

       26

   0.18

Anterior or posterior thigh

       4.75

     125

   0.87

Anterior or posterior calf

       3.5

       92

   0.64

Dorsal foot or sole, including toes

       1.75

       46

   0.32

TABLE 8

PSYCHIATRIC FUNCTIONAL IMPAIRMENT GUIDELINE SUMMARY

100

Total

70

Severe

50

Considerable

30

Definite

10

Mild

0

Remission

Competence PEB

Usually incompetent Usually incompetent

Usually competent Occasionally incompetent

Competent Competent

Competent Competent

Competent Competent

Competent Competent

Signs

Actively psychotic; totally out of contact with reality

Actively psychotic; intermittent contact with reality

Overt display of symptoms listed

Display signs/symptoms on exam

Minimal signs on probing

None

Hospitalization

Usually hospitalized Rarely with next of kin

Usually hospitalized Often with next of kin

Intermittent hospitalization

Not required

Not required

Not required

Supervision

Constant supervision/care

Required > 50% of time

Limited to none

Not required

Not required

Not required

Job Stability

Unemployable

Employable. Sheltered workshop

Extreme instability

Moderately unstable

Adequate job adjustment

Stable

Social Adjustment

Incapable of social adjustment

Minimal social adjustment

Significant social mal-adjustment

Borderline

Adequate

Satisfactory

Medication

Assume constant

Assume constant

Requires constant medication

Usually required

May require

No medication

Psychotherapy

Assume constant

Assume constant

Requires frequent psychotherapy

Usually required

May require or may need periodic monitoring of medications

Not required

Harm to self/others

Significant potential

Some potential

Low potential

Low potential

Very low potential

No