Department of Veterans Affairs M21-1, Part III, Subpart ivVeterans Benefits Administration January 31, 2018Washington, DC 20420

Key Changes

Changes Included in This Revision

The table below describes the changes included in this revision of Veterans Benefits Manual M21-1, Part III, “General Claims Process,” Subpart iv, “General Rating Process.”

Notes: M21-1, Part III, Subpart iv, Chapter 4, Section F (III.iv.4.F) previously

included guidance on rating disabilities of the endocrine system. That guidance was relocated to III.iv.4.M on December 11, 2017. III.iv.4.F is now being used to relocate and reorganize guidance on rating disabilities of the respiratory system. This section consists of material previously located in III.iv.4.D. Substantive changes to the relocated material are itemized in the table

below. Relocated text is not highlighted or shown as a tracked change. Only

edits made to the relocated text are shown using tracked changes and highlighted yellow text.

The term “regional office” (RO) also includes pension management center (PMC) and Appeals Resource Center (ARC), where appropriate.

Unless otherwise noted, the term “claims folder” refers to the official, numbered, Department of Veterans Affairs (VA) repository – whether paper or electronic – for all documentation relating to claims that a Veteran and/or his/her survivors file with VA.

Minor editorial changes have also been made to improve clarity and readability add references update incorrect or obsolete references reassign alphabetical designations to individual blocks, where necessary,

to account for new blocks within a topic update the labels of individual blocks and the titles of topics to more

accurately reflect their content, and bring the document into conformance with M21-1 standards.

Reason(s) for Notable Change CitationTo add a new Block h to incorporate guidance on considering diffusion capacity of the lung for carbon monoxide testing.

III.iv.4.F.1.h

To relocate old III.iv.4.D.1.p. To clarify that a sleep study is not required when clinical examination is

not indicative of sleep apnea.

III.iv.4.F.5.a

To add a new Block c on considering allergic rhinitis within scope of claimed sinusitis, as was previously directed in the October 2014 Compensation Service Bulletin.

III.iv.4.F.7.c

To add a new Block d on allergic rhinitis to incorporate guidance from 38 III.iv.4.F.7.d

CFR 3.380 and the example included in the August 2009 Inter-rater Reliability Study.

Reason(s) for Change CitationTo rename and reorganize Topic 1 to include basic rating principles for respiratory disabilities.

III.iv.4.F.1

To relocate old III.iv.4.D.1.g to a new Block a. III.iv.4.F.1.a To relocate old III.iv.4.D.1.h to a new Block b. To add a reference to Urban v. Shulkin, 29 Vet.App. 82 (2017).

III.iv.4.F.1.b

To relocate old III.iv.4.D.1.i to a new Block c. III.iv.4.F.1.cTo relocate old III.iv.4.D.1.j to a new Block d. III.iv.4.F.1.dTo relocate old III.iv.4.D.1.l-n to new Blocks e-g. III.iv.4.F.1.e-gTo add a new Topic 5 for reorganization of guidance on sleep apnea and related disabilities.

III.iv.4.F.5

To relocate old III.iv.4.D.1.s to a new Block b. To delete information about other qualifying breathing assistance

devices for relocation to a new Block c. To delete information about the requirement for breathing assistance

devices for treatment of sleep apnea for relocation to a new Block d.

III.iv.4.F.5.b

To add a new Block c to relocate guidance about other qualifying breathing devices previously located in old III.iv.4.D.1.s.

III.iv.4.F.5.c

To add a new Block d to relocate guidance about the requirement for breathing assistance devices for treatment of sleep apnea previously located in old III.iv.4.D.1.s.

III.iv.4.F.5.d

To relocate old III.iv.4.D.1.r to a new Block e. III.iv.4.F.5.eTo relocate old III.iv.4.D.1.q to a new Block f. III.iv.4.F.5.fTo add a new Topic 6 for relocation of guidance on respiratory tract infections.

III.iv.4.F.6

To relocate old III.iv.4.D.1.a to a new Block a. III.iv.4.F.6.aTo relocate old III.iv.4.D.1.c-e to new Blocks b-d. III.iv.4.F.6.b-dTo add a new Topic 7 for relocation of guidance on other respiratory disabilities.

III.iv.4.F.7

To relocate old III.iv.4.D.1.t to a new Block a. III.iv.4.F.7.aTo relocate old III.iv.4.D.1.b to a new Block b. III.iv.4.F.7.bTo relocate old III.iv.4.D.1.o to a new Block e. III.iv.4.F.7.eTo relocate old III.iv.4.D.1.f to a new Block f. III.iv.4.F.7.fTo relocated old III.iv.4.D.1.k to a new Block g. III.iv.4.F.7.g

Authority By Direction of the Under Secretary for Benefits

Signature

Beth Murphy, DirectorCompensation Service

Distribution LOCAL REPRODUCTION AUTHORIZED

Section FD. Respiratory Conditions

Overview

In This Section This section contains the following topics:

Topic Topic Name1 General Information onBasic Rating Principles for Respiratory

Conditions2 General Information on Tuberculosis3 Arrested Tuberculosis4 Exhibit 1: Examples of Ratings for Arrested Tuberculosis5 Sleep Apnea and Related Disabilities6 Respiratory Tract Infections7 Other Respiratory Disorders

1. General Information onBasic Rating Principles for Respiratory Conditions

Introduction This topic contains general information aboutbasic rating principles for respiratory conditions, including

types of chronic upper respiratory tract infections evaluating sinusitis identifying the cause of coexisting chronic upper respiratory tract infections continuous upper respiratory tract infections first manifest after discharge relationship between upper and lower respiratory tract infections evaluating spontaneous pneumothorax prohibition of separate evaluations for certain coexisting respiratory

disabilities evaluating coexisting respiratory disabilities example 1 – evaluating coexisting respiratory disabilities example 2 – evaluating coexisting respiratory disabilities evaluating gunshot wounds (GSWs) of muscle groups (MGs) I to IV and

XXI when requirement for pulmonary function tests (PFTs) are required assigning disability evaluations based on the results of PFTs post-bronchodilator studies, requirements, and evaluations, and diffusion capacity of the lung for carbon monoxide (DLCO) testing. complete organic aphonia and special monthly compensation (SMC) sleep apnea and sleep studies considering upper airway resistance syndrome (UARS) processing claims for increase in sleep apnea evaluating sleep apnea, and service connection (SC) for deviated nasal septum.

Change Date July 24, 2017January 31, 2018

ag. Prohibition of Separate Evaluations for Certain Coexisting Respiratory Disabilities

38 CFR 4.96(a) prohibits the assignment of separate evaluations for co-existing respiratory conditions rated under 38 CFR 4.97, diagnostic codes ( DCs ) 6600 through 6817 and 6822 through 6847 .

38 CFR 4.97, DCs 6819 and 6820 (malignant and benign neoplasms) are rated on residuals, including any residual disability of the respiratory system. Therefore, where there is lung or pleural involvement, separate evaluations under 38 CFR 4.97, DCs 6819 and 6820 are prohibited. If an evaluation has already been assigned under either 38 CFR 4.97, DCs 6819 or 6820, separate evaluations are also prohibited under 38 CFR 4.97, DCs 6600 through 6817 and 6822 through 6847.

Reference: For more information on pyramiding, see

38 CFR 4.14 M21-1, Part III, Subpart iv, 5.B.2.b, and Esteban v. Brown, 6 Vet.App. 259 (1994).

bh. Evaluating Coexisting Respiratory Disabilities

Under 38 CFR 4.96(a) when there are coexisting respiratory disabilities for which multiple evaluations cannot be assigned

a single rating will be assigned under the DC which reflects the predominant disability, and

t hat evaluation will be elevated to the next higher evaluation, when the severity of the overall disability warrants it.

Exception: In cases protected by the provisions of Public Law 90-493, the graduated ratings of 50 and 30 percent for inactive tuberculosis will not be elevated.

The Veterans Benefits Management System – Rating (VBMS-R) Evaluation Builder is programmed to appropriately apply the provisions of 38 CFR 4.96(a) but it is critical that

the user input the symptoms that support the elevation, and the symptoms coincide with the criteria listed in the rating schedule.

Refer to the table below fFor instructions on proper application of the 38 CFR 4.96(a) provision on assigning an evaluation in cases of multiple qualifying coexisting respiratory disabilities see the following table.

Step Action1 Determine which of the coexisting respiratory conditions is the

predominant disability.

Important: To determine the predominant disability, determine the

evaluation each condition would support warrant on its own. The condition that has the highest disability evaluation is the predominant disability.

If the same evaluation would be assigned to each, go through the analysis in the steps, alternatively treating each condition as the predominant one to see if one alternative provides a more advantageous outcome to the Veteran.

2 Determine if there are symptoms of the non-predominant disability that do not overlap with those of the predominant disability.

If yes, go to Step 3. If no, go to Step 4.

3 Reevaluate the predominant disability but this time also consider the non-overlapping symptoms of the non-predominant disability.

Important: The non-overlapping symptoms must support a higher evaluation when applied to the DC criteria being utilized for the predominant disability.

Determine if the resultant evaluation is higher than the evaluation for the symptoms of the predominant disability alone (as derived in Step 1).

If yes, go to Step 5. If no, go to Step 4.

4 Rate the cooexistent disabilities together under the rating criteria for the predominant disability without elevation to the next higher evaluation.

No further action necessary.5 Rate the coexistent disabilities together under the rating criteria

for the predominant disability and elevate to the next higher evaluation.

No further action necessary.

Important: The “next higher level of evaluation” is the lowest evaluation specified in

the DC for the predominant disability that provides greater compensation than the evaluation derived in Step 1 (the evaluation that would be supported by only the symptoms of the predominant disability without the symptoms of the lesser disability). Do not simply add 10 percent.

Although elevation remains a legal option under the existing regulatory language, because evaluations in the specified DCs overwhelmingly use mostly-overlapping and mostly-objective criteria, in many cases the result of the analysis specified in the table will be a conclusion that elevation is not appropriate.

References: For examples of assigning an evaluation in cases of multiple qualifying

coexisting respiratory disabilities see M21-1, Part III, Subpart iv, 4.FD.1.ci and dj, and

more information on application of 38 CFR 4.96(a), see Urban v. Shulkin, 29 Vet.App. 82 (2017).

ci. Example 1 – Evaluating Coexisting Respiratory Disabilities

Situation: Sleep apnea (38 CFR 4.97, DC 6847) warrants an evaluation of 50 percent based on the need for a continuous positive airway pressure (CPAP) machine. Chronic obstructive pulmonary disease (COPD) (38 CFR 4.97, DC 6604) is coexistent and warrants a 30-percent evaluation based on pulmonary function tests (PFTs).

Result: The predominant condition is the sleep apnea as it justifies a higher evaluation. There are no non-overlapping symptoms of COPD to establish any of the criteria for which the next higher (100 percent) evaluation could be

assigned for sleep apnea: chronic respiratory failure with carbon dioxide retention or cor pulmonale, or need for tracheostomy. Therefore elevation is not appropriate.

dj. Example 2 – Evaluating Coexisting Respiratory Disabilities

Situation: Asbestosis (38 CFR 4.97, DC 6833) warrants an evaluation of 30 percent based on Ddiffusion cCapacity of the lLung for Ccarbon Mmonoxide (DLCO). Asthma (38 CFR 4.97, DC 6602) is coexistent and warrants a 30-percent evaluation based on inhalational anti-inflammatory medication.

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

el. When Requirement for PFTs Are Required

When the rating schedule criteria includes PFT results, PFTs must be obtained except when

the results of a maximum exercise capacity test are of record and are 20 milliliters/per kilogram of body weight per minute (ml/kg/min) or less

pulmonary hypertension has been diagnosed cor pulmonale has been diagnosed right ventricular hypertrophy has been diagnosed there have been one or more episodes of acute respiratory failure, or outpatient oxygen therapy is required.

Notes: If a maximum exercise capacity test is not of record, evaluate based on

alternative criteria. A diagnosis of pulmonary hypertension requires objective documentation by an

echocardiogram or cardiac catheterization.

Reference: For more information on when PFTs are required, see 38 CFR 4.96(d).

fm. Assigning Disability Evaluations

The table below contains instructions for assigning disability evaluations based on the results of PFTs.

Based on the Results of PFTs

If … And … Then …PFTs are not consistent with clinical findings

the examiner does not state why PFTs are not a valid indication of respiratory disability

evaluate based on PFTs.

PFTs are not consistent with clinical findings

the examiner states why PFTs are not a valid indication of respiratory disability

evaluate based on alternative criteria.

there is a disparity between PFT results (FEV-1, FVC, FEV-1/FVC, DLCO)

the evaluation would differ depending on the test result used

use the test result that the examiner states most accurately reflects the level of disability.

FEV-1 is greater than 100 percent

FVC is greater than 100 percent

do not assign a compensable evaluation based on a decreased FEV-1/FVC ratio.

DLCO is not of record the examiner states why DLCO would not be useful or valid

evaluate based on alternative criteria.

DLCO is not of record the examiner does not state why DLCO would not be useful or valid

return the examination as insufficient and request clarification.

gn. Post-Bronchodilator Studies, Requirements, and Evaluations

Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when

the results of pre-bronchodilator PFTs are normal the examiner determines that post-bronchodilator studies should not be done

and states why, or using the DLCO score values (Clinicians have stated that bronchodilator use

has no effect on DLCO values.)

When evaluating based on PFTs, use post-bronchodilator results unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, use the pre-bronchodilator values for rating purposes.

h. DLCO Testing

When utilizing DLCO to evaluate a respiratory disability, only test results recognized as DLCO or DLCO by the single breath method (DLCO (SB)) will be utilized for rating purposes.

DLCO divided by alveolar volume (DLCO/VA) is a variant of DLCO (SB) in

which the DLCO is divided by the alveolar volume of the lungs. There is no provision for considering DLCO/VA under 38 CFR 4.96 or 38 CFR 4.97. Consequently, DLCO/VA cannot be utilized for rating purposes.

2. General Information on Tuberculosis

Introduction This topic contains general information about tuberculosis, including

tuberculosis classification standards considering infection caused by other mycobacteria diagnosing infection caused by other mycobacteria classifying disease caused by other mycobacteria considering chest x-rays under 38 CFR 3.370 and 38 CFR 3.371 referrals for x-ray interpretation under 38 CF. 3.370 and 38 CFR 3.371, and processing claims based on tuberculin reaction.

Change Date April 15, 2015

a. Tuberculosis Classification Standards

Become familiar with the following classification standards adopted by the American Lung Association under The Diagnostic Standards and Classification of Tuberculosis in Adults and Children, 1999:

Classify an individual as Tuberculosis Suspect until diagnostic procedures are complete. (Note: Do not use the classification Tuberculosis Suspect for more than three months.)

Classify disease caused by other mycobacteria as Other Mycobacterial Diseases. (Note: Disease caused by other mycobacteria is indistinguishable clinically, radiologically, and histologically from mycobacterium (M.) tuberculosis.)

Reference: For more information on the classification standards, see The Diagnostic Standards and Classification of Tuberculosis in Adults and Children , 1999 .

b. Considering Infection Caused by Other Mycobacteria

Other mycobacteria that may commonly be involved as pathogens are

M. kansasii M. intracellulare, and M. scrofulaceum.

Note: M. bovis is rarely responsible for disease where there is effective control of tuberculosis

in cattle and pasteurization of milk and milk products, and indistinguishable from M. tuberculosis except by culture.

c. Diagnosing Infection Caused by Other Mycobacteria

A definitive diagnosis for infection caused by other mycobacteria requires

evidence of disease (such as an infiltrate visible on a chest x-ray) no other cause established by careful clinical and laboratory studies, and either

appearance of the same strain of mycobacteria repeatedly, or isolation of the mycobacteria from a closed lesion from which the

specimen has been collected and handled under sterile conditions.

Note: Diagnosis of other mycobacterial infection by skin test is not possible. The current antigens for mycobacteria other than M. tuberculosis have high cross-reactivity and low specificity.

d. Classifying Disease Caused by Other Mycobacteria

With certain modifications, the classification for tuberculosis is adaptable for classifying other mycobacterial diseases.

When classifying mycobacterial diseases, do not use the following three categories used for tuberculosis

“no exposure, not infected” “exposure, no evidence of infection,” or “infection, without disease.”

e. Considering Chest X-Rays Under 38 CFR 3.370 and 38 CFR 3.371

If active pulmonary tuberculosis is claimed to be service-connected (SC) and entitlement is not established by other evidence, then consider the x-ray evidence in accordance with 38 CFR 3.370 and 38 CFR 3.371.

Reports of x-ray interpretations must be adequate for rating purposes.

Use the table below to determine which x-ray films are required to prove service connection (SC).

To prove … Films required are …direct SC all service films.presumptive SC discharge film (or a service film used for this) and

an adequate number of post-service films.

f. Referrals for X-Ray Interpretation Under 38 CFR 3.370 and 38 CFR 3.371

Only designees of the Under Secretary for Health are authorized to interpret x-ray films under 38 CFR 3.370 and 38 CFR 3.371. Refer requests for interpretations to the Department of Veterans Affairs (VA) medical facility for the local regional office (RO).

Note: If the local VA medical facility is not authorized to make such interpretations, the Director will keep the RO informed of the current location of the designated interpreter for the RO area. In such a case, refer requests directly to the clinic, center, or hospital.

g. Processing Claims Based on Tuberculin Reaction

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

3. Arrested Tuberculosis

Introduction This topic contains information about arrested tuberculosis, including

processing graduated ratings in effect on August 19, 1968 processing ratings in effect after August 19, 1968 requesting examinations during the graduated rating period processing notification of failure to follow treatment or submit to

examination, and processing cases of irregular discharge.

Change Date August 3, 2011

a. Processing Graduated Ratings in Effect on August 19, 1968

For graduated ratings in effect on August 19, 1968,

award a total evaluation for two years after the date of complete arrest or inactivity established under 38 CFR 3.375(a)

as set forth under the general rating formula following 38 CFR 4.97, DC 6724 of the rating schedule reduce the evaluation to 50 percent for four years, and reduce the evaluation to 30 percent for another five years, and

after the expiration of the 11-year period continue the 30-percent evaluation, if far advanced active lesions exist assign a 20-percent evaluation, if there are moderately advanced lesions

with continued disability, or assign a 0-percent evaluation if the first two criteria do not apply.

b. Processing Ratings in Effect After August 19, 1968

If pulmonary tuberculosis is established after August 19, 1968,

continue the 100-percent evaluation for one year after the date of inactivity established under 38 CFR 3.375(a), and

thereafter apply the general rating formula for residuals in the rating schedule under 38 CFR 4.97, DC 6731.

c. Requesting Examinations During the Graduated Rating Period

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

d. Processing Notification of Failure to Follow

Medical authorities will notify the RO of a Veteran’s failure to follow prescribed treatment or submit to examination requested for treatment purposes during the period of total disability following complete arrest of the

Treatment or Submit to Examination

tuberculosis.

After the notification is received, follow the due process procedures of 38 CFR 3.655 and furnish the Veteran a notice of proposed adverse action. Upon expiration of the due process period

reduce the 100-percent evaluation to 50 percent by rating action, and adjust the Veteran’s award as of the date of the last payment or the date

indicated in the notice of proposed adverse action, whichever is later.

Notes: The reduction of the 100-percent evaluation upon failure to submit to

examination or follow prescribed treatment is applicable only when the tuberculosis has reached a stage of complete arrest or inactivity.

If the Veteran complies with the request for examination during the original two-year time frame for the 100-percent graduated rating, restore the 100-percent rating effective the date of reduction.

e. Processing Cases of Irregular Discharge

Do not suspend or discontinue payments merely because a Veteran with active tuberculosis receives an irregular discharge. An irregular discharge is received for disciplinary reasons, the refusal to accept or follow treatment, the refusal to accept transfer, or failure to return from an authorized absence.

In the case of irregular discharge,

continue the 100-percent evaluation based on activity, and request an examination six months from the date of irregular discharge.

If the Veteran fails to report for this examination, consider the tuberculosis to be completely arrested from the date of failure to report for examination. Apply the provisions of graduated ratings based upon inactivity from this date.

Note: Compensation payments are based upon the degree of disability, not on the basis of a Veteran’s willingness to accept treatment.

4. Exhibit 1: Examples of Ratings for Arrested Tuberculosis

Introduction This exhibit contains four examples of ratings for arrested tuberculosis.

Change Date December 29, 2007

a. Example 1 Situation: A Veteran is 30-percent disabled based upon residuals of far advanced, inactive, pulmonary tuberculosis. The rating for tuberculosis was in effect on August 19, 1968. The tuberculosis became active on September 10, 2002.

Result: Based upon the reactivation of pulmonary tuberculosis, reinstate the 100-percent evaluation for active tuberculosis and maintain control to ascertain the date of inactivity.

Coded Conclusion1. SC (KC PRES)6701 Tuberculosis, pulmonary, chronic,

far advanced, active30% from 08/01/1964100% from 09/10/2002

b. Example 2 Situation: Same facts as in Example 1. Examination reveals tuberculosis was inactive as of May 10, 2003.

Result: Continue the 100-percent evaluation for two years after the date of inactivity, followed by graduated reduction to 50 percent thereafter for four years. Reduce to 30 percent from May 10, 2009, and thereafter based on far advanced lesions.

Coded Conclusion1. SC (KC PRES)6721 Tuberculosis, pulmonary, chronic,

far advanced inactive100% from 09/10/2002100% from 05/10/200350% from 05/10/200530% from 05/10/2009

c. Example 3 Situation: Same facts as in Example 2. Medical authorities provide notification of the Veteran’s failure to submit to examination for treatment purposes. The notice of proposed adverse action advised that payments would be reduced effective June 1, 2004, but the date of last payment at the

expiration of the due process period was July 1, 2004.

Result: Reduce the evaluation for pulmonary tuberculosis to 50 percent effective the date of last payment and to 30 percent four years later.

Coded Conclusion1. SC (KC PRES)6721 Tuberculosis, pulmonary, chronic,

far advanced inactive100% from 05/10/200350% from 07/01/200430% from 07/01/2008

d. Example 4 Situation: Same facts as in Example 3. Medical authorities provide notification the Veteran has reported for examination on March 10, 2005. The tuberculosis remains inactive.

Result: Reinstate the 100-percent evaluation and reduce the evaluation to 50 percent two years after the date of inactivity of pulmonary tuberculosis. Reduce to 30 percent four years later.

Coded Conclusion:1. SC (KC PRES)6721 Tuberculosis, pulmonary, chronic,

far advanced inactive100% from 05/10/200350% from 05/10/200530% from 05/10/2009

5. Sleep Apnea and Related Disabilities

Introduction This topic contains general information about sleep apnea and related disabilities, including

sleep apnea and sleep studies evaluating sleep apnea qualifying devices for sleep apnea treatment required use of a breathing assistance device processing claims for increase in sleep apnea, and considering upper airway resistance syndrome (UARS).

Change Date January 31, 2018

ap. Sleep Apnea and Sleep Studies

The diagnosis of sleep apnea must be confirmed by sleep study for compensation rating purposes. Receipt of medical evidence disclosing a diagnosis of sleep apnea without confirmation by a sleep study is sufficient to trigger the duty to assist for scheduling an examination if the other provisions of 38 CFR 3.159(c)(4) have been satisfied. However, such evidence is not sufficient to award SC for sleep apnea.

When clinical examination leads to the conclusion that symptoms of sleep apnea are present, the subsequent diagnosis of sleep apnea must be confirmed by sleep study for compensation purposes.

Do not establish SC for sleep apnea that has not been confirmed by a sleep study.

However, if clinical indicators of sleep apnea are not found on examination, a sleep study is not required to rule out the sleep apnea diagnosis.

Important: A Accept a home sleep study is only accepted if it has been clinically determined that the Veteran can be appropriately

evaluated by a home sleep study, and a competent medical provider has evaluated the results.

Reference: For more information about types of medical providers qualified to provide medical evidence, see M21-1, Part III, Subpart iv, 3.D.2.

bs. Evaluating Sleep Apnea

Evaluate sleep apnea using the criteria in 38 CFR 4.97, DC 6847 (sleep apnea syndromes (obstructive, central, mixed).

When determining whether the 50-percent criteria are met, the key consideration is whether use of a qualifying breathing assistance device is required by the severity of the sleep apnea.

There are two related considerations, which are

what whether a devices qualifiesy, as discussed in M21-1, Part III, Subpart iv, 4.F.5.c, and

whether if use of a qualifying device is necessary, as discussed in M21-1, Part III, Subpart iv, 4.F.5.d.

On the question of what qualifies as a breathing assistance device, the DC lists a CPAP machine as an example.

Other qualifying breathing assistance devices include: other positive airway pressure machines (automatic positive airway pressure

device (APAP); bilevel positive airway pressure device (BiPAP)) nasopharyngeal appliances (nasal dilators; nasopharyngeal stents) oral appliances (mandibular advancement devices (MAD); tongue-retaining

mouthpieces), and implanted genioglossal nerve stimulation devices.

Note: Positive airway pressure machines may also be called non-invasive positive pressure ventilation (NIPPV) or non-invasive ventilation (NIV).

On the question of whether sleep apnea requires use of a breathing device, there are two important and related points

Use absent a medical determination that the device is necessary does not qualify. The regulation requires that the device be necessary and this is a medical question.

If the competent medical evidence of record shows that use of a qualifying breathing assistance device is medically required, the fact that the claimant is not actually using it as prescribed is not relevant.

c. Qualifying Devices for Sleep Apnea Treatment

38 CFR 4.97, DC 6847 lists a CPAP machine as an example of a breathing assistance device for treatment of sleep apnea which is required for assignment of the 50 percent evaluation.

Other qualifying breathing assistance devices include

other positive airway pressure machines (automatic positive airway pressure device (APAP); bilevel positive airway pressure device (BiPAP))

nasopharyngeal appliances (nasal dilators; nasopharyngeal stents) oral appliances (mandibular advancement devices (MAD); tongue-retaining

mouthpieces), and implanted genioglossal nerve stimulation devices.

Note: Positive airway pressure machines may also be called non-invasive positive pressure ventilation (NIPPV) or non-invasive ventilation (NIV).

d. Required Use of a Breathing Assistance Device

Assignment of the 50-percent evaluation for sleep apnea under 38 CFR 4.97, DC 6847 entails the required use of a breathing assistance device. Consider the factors below in determining whether the criteria for required use of a breathing assistance device are satisfied.

Use of a device absent a medical determination that the device is necessary does not qualify. The regulation requires that the device be necessary, and this is a medical question.

If the competent medical evidence of record shows that use of a qualifying breathing assistance device is medically required, the fact that the claimant is not actually using it as prescribed is not relevant.

er. Processing Claims for Increase in Sleep Apnea

Follow the steps in the table below to process a claim for increase in sleep apnea.

Step Action1 Is there a sleep study confirming the diagnosis of sleep apnea?

If yes, go to Step 6. If no, go to Step 2.

2 Has SC for sleep apnea been in effect for 10 years or more?

If yes, go to Step 6. If no, go to Step 3.

3 Request an examination with sleep study to confirm the diagnosis.

Go to Step 4.4 Does the sleep study confirm the diagnosis of sleep apnea?

If yes, go to Step 6. If no, go to Step 5.

5 Prepare a proposal to sever SC for sleep apnea in accordance with 38 CFR 3.105(d).

Reference: For more information on preparing proposed rating decisions, see M21-1, Part III, Subpart iv, 8.B.1.

6 Perform any additional development as necessary, continue SC for sleep apnea, and assign an evaluation based on the evidence of record.

fq. Considering UARS

Upper airway resistance syndrome (UARS) represents a progression toward the potential development of sleep apnea, caused by snoring. However, UARS, in and of itself, does not meet the criteria of sleep-disordered breathing that defines sleep apnea and is not considered a ratable disability for compensation purposes.

In order to dispose of a claim for SC where only an assessment of UARS is shown, the rating activity must

deny SC in the absence of a diagnosed chronic disability code the issue as analogous to sleep apnea under 38 CFR 4.97, DC 6847,

and inform the Veteran that he/she may submit a request for reconsideration or

claim to reopen if a clinical diagnosis of sleep apnea is subsequently confirmed.

Example:

References: For more information on sleep apnea and sleep studies, see M21-1, Part III, Subpart iv, 4.FD.51.pa subthreshold diagnoses, see M21-1, Part IV, Subpart ii, 2.A.2.a sleep disorders examination review, see M21-1, Part III, Subpart iv,

3.D.4.m, and using analogous DCs, see M21-1, Part III, Subpart iv, 6.E.2.a and b.

6. Respiratory Tract Infections

Introduction This topic contains general information about respiratory tract infections, including

types of chronic upper respiratory tract infections identifying the cause of coexisting chronic upper respiratory tract infections continuous upper respiratory tract infections that first manifest after

discharge, and relationship between upper and lower respiratory tract infections.

Change Date January 31, 2018

a. Types of Chronic Upper Respiratory Tract Infections

Chronic upper respiratory tract infections include

chronic rhinitis chronic sinusitis chronic tonsillitis, and chronic laryngitis.

bc. Identifying the Cause of Coexisting Chronic Upper Respiratory Tract Infections

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

cd. Continuous Upper Respiratory Tract Infections That First Manifest After Discharge

If all respiratory conditions do not originate in service, there must be evidence of a fairly continuous infection in one or more parts of the upper respiratory tract to warrant service connection (SC) for other conditions first manifest after discharge.

Carefully consider the character of the infection and possible intervening causes.

de. Relationship Between Upper and Lower Respiratory Tract Infections

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

7. Other Respiratory Disabilities

Introduction This topic contains general information about other respiratory disabilities, including

deviated nasal septum sinusitis considering allergic rhinitis within scope of claimed sinusitis allergic rhinitis complete organic aphonia and special monthly compensation (SMC) spontaneous pneumothorax, and gunshot wounds (GSWs) of muscle groups (MGs) I to IV and XXI.

Change Date January 31, 2018

ta. SC for Deviated Nasal Septum

SC cannot be granted for a deviation of the nasal septum unless trauma is shown.

Reference: For more information on traumatic nasal septum deviation see 38 CFR 4.97, DC 6502 .

b. Evaluating Sinusitis

Evaluate sinusitis under 38 CFR 4.97, diagnostic codes ( DCs ) 6510 through 6514.

When applying the higher of two possible evaluations under 38 CFR 4.7, a history of radical surgery or repeated surgeries is not required if the criteria under the rating formula are otherwise met.

Example: The application of 38 CFR 4.7 results in an evaluation of 50 percent when the evidence shows chronic osteomyelitis, or near constant sinusitis, characterized by

headaches pain and tenderness of affected sinus, and purulent discharge, and

no evidence of radical surgery or repeated surgery.

Reference: For more information on the schedule of rating respiratory conditions, see 38 CFR 4.97.

c. Considering Allergic Rhinitis Within Scope of

When a claim for SC for sinusitis is received but compensation examination reveals a diagnosis of allergic rhinitis and not sinusitis and associates the rhinitis with service, consider allergic rhinitis within scope of the claim for

Claimed Sinusitis

SC for sinusitis. In this situation

do not return the examination for clarification of a diagnosis if the examination is otherwise sufficient

grant SC for allergic rhinitis if otherwise supported by the evidence of record, and

deny SC for sinusitis, if sinusitis is not shown.

Reminder: If both sinusitis and rhinitis are shown and the requirements for SC are met for both conditions, grant SC for each condition separately and combine as usual under 38 CFR 4.25.

Reference: For more information on considering issues within scope of a claim, see M21-1, Part III, Subpart iv, 6.B.2.c, and 38 CFR 3.155(d)(2) .

d. Allergic Rhinitis

38 CFR 3.380 directs that diseases of allergic etiology are not to be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. When considering SC for allergic rhinitis, consider whether

the disability existed prior to service, and whether the disability is chronic and persistent in relation to exposure to and

removal from the allergen.

The determination as to service incurrence must be based on the whole evidentiary showing.

Example: Veteran claims SC for allergic rhinitis. The nose and sinuses were normal at enlistment with no allergies noted. During his 20 year military career, the Veteran was treated variably for symptoms of upper respiratory infection, congestion, rhinitis, seasonal allergic rhinitis, perennial allergic rhinitis, and seasonal allergies throughout service. Clear diagnoses of allergies and allergic rhinitis were noted during service including on the retirement physical. At the compensation examination, the Veteran reported episodic sinusitis and ongoing allergic rhinitis with seasonal symptoms and the use of medications for treatment. Examination revealed no obstruction or deviation. No rhinitis or sinusitis were active on examination. The diagnosis was seasonal allergic rhinitis.

Result: The Veteran had a long and recurring history of complaints of, treatment for, and diagnosis of allergic rhinitis and upper respiratory symptoms during service. There is no evidence of a pre-service history of allergic rhinitis. Veteran is entitled to SC with a noncompensable evaluation for allergic rhinitis as evidence showed incurrence in service.

eo. Complete Award special monthly compensation (SMC) if complete organic aphonia

Organic Aphonia and SMC

results in the constant inability to communicate by speech.

Reference: For more information on awarding SMC for organic aphonia, see 38 CFR 3.350(a)(6) 38 CFR 4.96 38 CFR 4.97, DC 6519 M21-1, Part IV, Subpart ii, 2.H.4.i, and M21-1, Part IV, Subpart ii, 2.I.2.g.

f. Evaluating Spontaneous Pneumothorax

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

Evaluate pneumothorax under 38 CFR 4.97, DC 6843.

gk. Evaluating GSWs of MGs I to IV and XXI

When evaluating gunshot wounds (GSWs) of muscle groups (MGs) I through IV and MG XXI, an evaluation under the general rating formula for restrictive lung disease, which covers 38 CFR 4.97, DCs 6840 through 6845, must be considered.

A minimum evaluation of 20 percent must be assigned if there is

a bullet or missile retained in the lung pain or discomfort on exertion scattered rales limitation of excursion of diaphragm, or limitation of excursion of lower chest expansion.

Notes: Separate ratings may be awarded for MGs I through IV and ratings for

respiratory impairment. A GSW of MG XXI will not be separately evaluated from the respiratory

disability under restrictive lung disease criteria. Assign a single evaluation for injury to MG XXI and any respiratory impairment.