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Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations structural abnormalities exist, if they are not associated with a specific disability or disabilities, then such abnormalities are not a basis for disability compensation. Second, the Compendium of Physical Activities, which is a coding scheme that classifies specific physical activity . . .
by rate of energy expenditure, https
pubmed.ncbi.nlm.nih.gov/10993420/, shows that while the amount of energy expended depends on the duration of the activity, the rate of energy expenditure is unchanged regardless of how long the energy is expended.
Finally, VA notes that the fact that a disease classification system functions well in terms of guiding treatment or predicting prognosis does not necessarily imply it is an adequate tool for rating disabilities. Pursuant to 38
U.S.C. 1155, VAs rating schedule is intended to reflect reductions in earning capacity from specific injuries or disabilities incurred in or due to military service, so any proposed classification system must fulfill that requirement.

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Specific Diagnostic Codes DCs Proposed new DC 7009, bradycardia bradyarrhythmia, symptomatic, requiring permanent pacemaker implantation and current DC 7018, implantable cardiac pacemakers:
One commenter asked if a 100-percent evaluation for implanted pacemakers could be prolonged if recovery time was greater than one month. VA proposed to add a new DC 7009 for bradycardia requiring permanent pacemaker implantation that would provide a 100percent evaluation for one month following hospitalization for implantation or re-implantation.
Residuals after the following initial month will be evaluated using the General Rating Formula. Aside from total 100 percent evaluations provided in the rating schedule, VA also provides temporary 100-percent evaluation ratings for any service-connected disability that requires hospitalization longer than 21 days or more or requires at least one month of convalescence for surgery or immobilization by cast of one major joint or more, if the evidence shows that it is warranted. See 38 CFR
4.294.30. Since VA has provisions in place for post-operative or surgical total evaluations for such instances, VA
makes no changes based on this comment.
Proposed new DC 7009, bradycardia bradyarrhythmia, symptomatic, requiring permanent pacemaker implantation and current DCs 7010, supraventricular arrhythmias, 7011,
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ventricular arrhythmias sustained, and 7015, atrioventricular block:
The proposed rule stated that, for conditions under these DCs, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture. One commenter asked how a medical professional could appeal or otherwise alter the diagnostic code to the extent that person disagrees with that instruction. VA clarifies that predominant disability picture is a term of art that generally describes the disability that allows for the highest compensable evaluation. To the extent the commenter means to ask whether an examiner can provide additional information beyond what he or she believes is contemplated by the applicable diagnostic code, the answer is that an examiner should always strive to provide a complete picture of the claimants disability, including any salient details, and provide medical reasoning to justify any conclusions drawn, which is consistent with the examiners obligations under 38 CFR
4.10. If a veteran is service connected for two of these disabilities, a VA rating specialist will consider the probative value of this report in selecting the disability that warrants the highest evaluation to evaluate both conditions, consistent with the raters obligation to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 CFR
4.2.
If the claimant or the claimants representative believes another serviceconnected condition is more disabling to the point that it warrants a higher evaluation than the original condition, the claimant or the claimants representative may present evidence in support of that argument in whatever posture is most appropriate at the time.
For example, the claimant may raise that argument in a notice of disagreement if filed within one year of the rating decision notification letter containing the disputed disability picture assessment, or the claimant may file an increased rating claim if the other service-connected condition has become the prominent disability any time after the initial rating decision becomes final.
At that time, if the rating specialist determines the evidence supports the claimants argument, VA will assign a new higher evaluation to reflect the appropriate disability picture. VA
makes no changes based on this comment.

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DC 7010, Supraventricular Arrythmias:
Four different commenters raised multiple concerns with this DC. Two commenters raised the issue of hospitalizations, one objecting to the use in the revised evaluation criteria and the other asking what level of hospitalization is required to receive an evaluation. VA used the term hospitalizations in giving a general description of the evaluation criteria revisions, but the proposed rule goes on to state VAs actual intent, which was to use specific treatment interventions such as intravenous pharmacologic adjustment, cardioversion, and/or ablation from a provider that are intended to treat acutely disabling symptoms. Hospitalization may or may not be associated with these treatment interventions, so it was excluded as a description within the evaluation criteria. VA regrets any confusion resulting from the use of the word hospitalizations in association with this DC and continues with the proposed changes without modification.
Three commenters proposed oral medication be used within evaluation criteria. One commenter proposed adding emergency room ER visits to the evaluation criteria. Still another commenter proposed adding vagal maneuvers to the evaluation criteria. VA
agrees to incorporate oral medications and vagal maneuvers but declines to revise the evaluation criteria to incorporate ER visits. As previously stated, the evaluation criteria will be based on residual disability from treatment interventions to resolve disabling symptoms. ER visits do not necessarily require intravenous pharmacologic adjustment, cardioversion, or ablation to block or control the condition and any associated disability. When they do, the proposed evaluation criteria can accommodate this situation.
Finally, two commenters stated that the criteria did not account for other symptoms associated with supraventricular tachycardia, specifically extreme fatigue and tachycardia that induces hypotension, shortness of breath, dizziness, and chest pain. VA declines to revise the evaluation criteria to incorporate symptoms of extreme fatigue, hypotension, shortness of breath, dizziness, and chest pain. This DC
specifically addresses supraventricular tachycardia; however, if the condition also causes ventricular arrhythmias i.e., tachycardia and bradycardia, an evaluation can be assigned using DC
7011 under the general rating formula, which considers symptoms of fatigue,
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