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Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more adjusted annually for inflation in any year. This final rule would have no such effect on State, local, and tribal governments, or on the private sector.
Paperwork Reduction Act This final rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 44 U.S.C. 35013521.
Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.104, Pension for Non-Service-Connected Disability for Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death.

designated this rule as not a major rule, as defined by 5 U.S.C. 8042.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
Signing Authority Denis McDonough, Secretary of Veterans Affairs, approved this document on June 23, 2021, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.
Jeffrey M. Martin, Assistant Director, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs.

For the reasons set out in the preamble, VA amends 38 CFR part 4 as follows:
PART 4SCHEDULE FOR RATING
DISABILITIES
1. The authority citation for part 4
continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

Congressional Review Act
Subpart BDisability Ratings
Pursuant to the Congressional Review Act 5 U.S.C. 801 et seq., the Office of Information and Regulatory Affairs

2. Amend 4.100 by revising paragraph b and adding an authority at the end of the section to read as follows:

54093

4.100 Application of the evaluation criteria for diagnostic codes 70007007, 7011, and 70157020.

b Even if the requirement for a 10%
based on the need for continuous medication or 30% based on the presence of cardiac hypertrophy or dilatation evaluation is met, METs testing is required in all cases except:
1 When there is a medical contraindication.
2 When a 100% evaluation can be assigned on another basis.
Authority: 38 U.S.C. 1155

3. Amend 4.104 by:
a. Adding introductory text under the heading Diseases of the Heart;
b. Revising notes 1 and 2;
c. Adding note 3;
d. Adding an entry for General Rating Formula for Diseases of the Heart after note 3;
e. Revising the entries for DCs 7000, 7001, 7002, 7003, 7004, 7005, 7006, 7007, and 7008;
f. Adding an entry for DC 7009;
g. Revising the entries for DCs 7010, 7011, 7015, 7016, 7017, 7018, 7019, 7020, 7110, 7111, 7113, 7114, 7115, 7117, 7120, and 7122; and h. Adding DC 7124.
The revisions and additions read as follows:

4.104 Schedule of ratings cardiovascular system.

DISEASES OF THE HEART
Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.

LOTTER on DSK11XQN23PROD with RULES1

Rating Note 1: Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it.
Note 2: One MET metabolic equivalent is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5
milliliters per kilogram of body weight per minute. When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner may estimate the level of activity expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow that results in those symptoms.
Note 3: For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope.
GENERAL RATING FORMULA FOR DISEASES OF THE HEART:
Workload of 3.0 METs or less results in heart failure symptoms
Workload of 3.15.0 METs results in heart failure symptoms
Workload of 5.17.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent e.g., multigated acquisition scan or magnetic resonance imaging
Workload of 7.110.0 METs results in heart failure symptoms; or continuous medication required for control
7000 Valvular heart disease including rheumatic heart disease, 7001 Endocarditis, or 7002 Pericarditis:
During active infection with cardiac involvement and for three months following cessation of therapy for the active infection Thereafter, with diagnosis confirmed by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization, use the General Rating Formula.
7003 Pericardial adhesions.
7004 Syphilitic heart disease:
Note: Evaluate syphilitic aortic aneurysms under DC 7110 Aortic aneurysm: Ascending, thoracic, abdominal.
7005 Arteriosclerotic heart disease coronary artery disease.
Note: If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other nonarteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms.
7006 Myocardial infarction:
During and for three months following myocardial infarction, confirmed by laboratory tests

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