ࡱ> #` Dbjbjmm 4 <>>>>>>>|dhfhfhf8fDnmmDnDn>>2l2lh-(sssDn>2l>2lHsDnȚssϋA>>2lh pWUhfn"U<2fpJD>TDnDnsDnDnDnDnDnrFDnDnDnDnDnDnDn(((d.DW$(((DWRrx>>>>>> Section G. Neurological Conditions and Convulsive Disorders  PRIVATE INFOTYPE="OTHER" Overview In this Section This section contains the following topics: TopicTopic NameSee Page25General Information on Neurological and Convulsive Disorders4-G-226Multiple Sclerosis4-G-10 25. General Information on Neurological and Convulsive Disorders  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains general information about neurological and convulsive disorders, including determining service connection for neurological disorders rating progressive spinal muscular atrophy fully considering residuals of Traumatic Brain Injury (TBI) rating considerations in TBI cases multiple evaluations and pyramiding in TBI cases identifying epilepsy establishing presumptive service connection for amyotrophic lateral sclerosis (ALS) assigning a 100 percent minimum evaluation for ALS, and rating guidelines for ALS. Change DateJune 5, 2012 PRIVATE INFOTYPE="CONCEPT"  a. Determining Service Connection for Neurological DisordersThe field of neurological and mental diseases includes as varied a group as any in the field of medicine with regard to etiology, manifestations, and severity of the diseases. When considering relationship to service or disabling effects, view neurological disorders not as a class but individually, bearing in mind the etiology and clinical course of each separate disease. When considering conditions of infectious origin, be aware of the circumstances of infection, and the incubation period. Note: There is a large group of diseases, such as multiple sclerosis, progressive muscular atrophy, and myasthenia gravis, in which increased symptomatology over a period of a few months generally reflects natural progression of the disease. Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  PRIVATE INFOTYPE="CONCEPT"  b. Rating Progressive Spinal Muscular AtrophyProgressive muscular atrophy, diagnostic code (DC) 8023, refers to progressive spinal muscular atrophy, which is a disease of the spinal cord. Progressive muscular atrophy is subject to presumptive service connection under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_309.DOC"38 CFR 3.309(a) because it is an organic disease of the nervous system. PRIVATE INFOTYPE="CONCEPT"  c. Fully Considering Residuals of Traumatic Brain Injury Signs and symptoms of TBI may include, but are not limited to, those listed in the table below. Physical Cognitive Behavioral/Emotional Apraxia (inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness) Dementias (pre-senile Alzheimers type, dementia pugilistica, post traumatic dementia) Depression Aphasia (difficulty communicating orally and/or in writing) Attention and concentration deficits Agitation and irritability Paresis (muscle weakness or incomplete paralysis) Memory and learning impairment Impulsivity Plegia (suffix meaning paralysis or stroke) Language deficiencies Aggression Dysphagia (difficulty swallowing) Planning difficulties Anxiety Disorders of balance and coordination Judgment and control difficulties Diseases of hormone deficiency Reasoning and abstract thinking limitations Parkinsonism Nausea/vomiting Headaches Dizziness Blurred vision Seizure disorder Sensory loss Weakness Sleep disturbance Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  STYLEREF "Block Label" c. Fully Considering Residuals of Traumatic Brain Injury (continued)Most signs and symptoms of TBI will manifest immediately following the traumatic event, but some may be delayed from days to months. They may occur alone or in varying combinations. Important: A claim for compensation for symptoms of TBI is a claim for all identifiable residuals of the injury. References: For more information on determining the issues, see  HYPERLINK "imi-internal:M21-1MRIII.iv.6.B" M21-1MR Part III, Subpart iv, 6.B, and second signature requirement in TBI ratings, see  HYPERLINK "imi-internal:M21-1MRIII.iv.6.D.20.e" M21-1MR Part III, Subpart iv, 6.D.20.e.  PRIVATE INFOTYPE="PRINCIPLE"  d. Rating Considerations in Traumatic Brain Injury CasesRate residuals of TBI under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_124a.DOC"38 CFR 4.124a (DC 8045). In every case, one evaluation should be assigned using the highest level of impairment assigned to any facet contained in the table Evaluation of Cognitive Impairment and Other Residuals of TBI not Otherwise Classified. As a general rule, an additional evaluation(s) may be warranted for other physical (including neurological) or mental dysfunction under an appropriate DC. Reference: For more information on multiple evaluations and pyramiding, see  HYPERLINK "imi-internal:M21-1MRIII.iv.4.G.25.e" M21-1MR, Part III, Subpart iv, 4.G.25.e, and the  HYPERLINK "http://vbacodmoint1.vba.va.gov/bl/21/TBI/default.asp" TBI Text Generator tool for generating rating narrative, see the  HYPERLINK "http://vbaw.vba.va.gov/VetsNet/RBA2000_Docs/webhelp/RBA2000_Help.htm" RBA2000 Users Guide.  Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  e. Multiple Evaluations and Pyramiding in TBI CasesWhen rating a TBI case, you must ensure that multiple evaluations do not pyramid, which means that the same disability or component of disability cannot be compensated under multiple diagnostic codes. Note 1 to DC 8045 provides that there may be an overlap of manifestations listed and evaluated under the table Evaluation of Cognitive Impairment and Other Residuals of Residuals of TBI Not Otherwise Classified with manifestations of a comorbid mental, neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. The following table states the policy to follow. If ... Then ... manifestations are clearly separable assign a separate evaluation using each applicable diagnostic code. the manifestations of two or more conditions cannot be clearly separated assign a single evaluation under whichever set of criteria allows the better assessment of the overall impaired functioning due to both conditions. Important: Ensure that you have sufficiently clear and unequivocal medical opinion evidence on the key question of separability. If a medical provider cannot make the required determination without resorting to mere speculation, then careful consideration must be given to whether that statement can be accepted under  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bmj" Jones v. Shinseki, 23 Vet. App. 382 (2010). References: For more information on pyramiding see  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_14.DOC" 38 CFR 4.14, and  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bme" Esteban v. Brown, 6 Vet. App. 259 (1994).Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  f. Identifying EpilepsySeizures must be witnessed or verified by a physician to warrant service connection for epilepsy. Verification may be by an electroencephalogram (EEG), which measures electrical activity in the brain. A physician does not have to witness an actual seizure before a diagnosis of epilepsy can be accepted for rating purposes. Verification by a physician based upon factors other than observing an actual seizure is sufficient. Reference: For more information on identifying epilepsy, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_120.DOC"38 CFR 4.121, and psychomotor epilepsy, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_122.DOC"38 CFR 4.122.Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  g. Establishing Presumptive Service Connection for ALSEffective September 23, 2008, HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_318.DOC"38 CFR 3.318 established a presumption of service connection for amyotrophic lateral sclerosis (ALS) for any Veteran who had active, continuous service of 90 days or more, and develops the disease at any time after discharge from active service. Note: ALS, also called Lou Gehrigs disease, is a neuromuscular disease that causes degeneration of nerve cells in the brain and spinal cord, resulting in muscle weakness, muscle atrophy, and spontaneous muscle activity.  PRIVATE INFOTYPE="PRINCIPLE"  h. Assigning a 100 Percent Minimum Evaluation for ALSALS is rated under DC 8017 A diagnosis of ALS alone is sufficient to support the assignment of a 100 percent evaluation. However, total disability compensation should be seen as a minimum evaluation for the disorder because of the possibility of special monthly compensation. Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  i. Rating Guidelines for ALSDetermine the proper evaluation for all complications of ALS prior to coding a single 100 percent evaluation under DC 8017. If ... Then ... If there is no complication warranting a single 100 percent evaluation, assign a 100 percent evaluation under DC 8017. Include all compensable complications in the description of the diagnosis. Example: amyotrophic lateral sclerosis with loss of use of the left foot and partial ninth cranial nerve paralysis. If a single 100 percent evaluation is warranted for a complication of ALS, assign a 100 percent evaluation for that complication. Use a hyphenated diagnostic code. Example: 8017-5109, loss of use of both feet. separately evaluate additional complications. Do not assign a separate evaluation under DC 8017 alone; this would be pyramiding under  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_14.DOC" 38 CFR 4.14. Note: A 100 percent evaluation for a complication of ALS satisfies the policy that all cases of ALS will be assigned at least a 100 percent evlauation Continued on next page  STYLEREF "Map Title" 25. General Information on Neurological and Convulsive Disorders, Continued  STYLEREF "Block Label" i. Rating Guidelines for ALS (continued)Important: ALS cases will often implicate special monthly compensation (SMC) or other ancillary benefits. You must ensure that the codesheet reflects all complications that can be separately evaluated. When a 100 percent evaluation can be assigned for a single complication of ALS, other service-connected conditions, including separately ratable complications of ALS, may warrant entitlement to SMC at the statutory housebound rate. When a 100 percent evaluation is assigned for ALS to include complications, although the complications are not separately evaluated on the codesheet there may be entitlement to SMC (e.g. SMC K for loss of use of a foot). References: For more information on special monthly compensation, see  HYPERLINK "imi-internal:M21-1MRIV.ii.2.H" M21-1MR Part IV, Subpart ii, 2.H, ancillary benefits (generally), see  HYPERLINK "imi-internal:M21-1MRIII.ii.2.A.4" M21-1MR Part III, Subpart ii, 2.A.4 , specially adapted housing or special home adaptation grants, see  HYPERLINK "imi-internal:M21-1MRIX.i.3" M21-1MR Part IX, Subpart i, 3 and automobile allowance and adaptive equipment, see  HYPERLINK "imi-internal:M21-1MRIX.i.2" M21-1MR Part IX, Subpart i, 2.  26. Multiple Sclerosis  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about multiple sclerosis, including the definition of the term multiple sclerosis rating a residual disability 30 percent or more, and example of rating residual disability 30 percent or more. Change DateAugust 3, 2011 PRIVATE INFOTYPE="CONCEPT"  a. Definition: Multiple SclerosisMultiple sclerosis is a slowly progressive central nervous system disease, and is characterized by disseminated patches of demyelination in the brain and spinal cord which cause multiple and varied neurologic symptoms and signs, and the occurrence of remissions and exacerbations in the symptoms. PRIVATE INFOTYPE="PRINCIPLE"  b. Rating Residual Disability 30 Percent or MoreIn cases of multiple sclerosis evaluate each affected system or body part separately show the diagnostic code for multiple sclerosis only once by listing it with the most severely affected function code involvement of other manifestations thereafter under the DC assignable for the condition on which the evaluation is based, and show the remaining conditions as secondary to multiple sclerosis. Notes: This is a change from the previous requirement to rate multiple sclerosis as a single disability when the combined degree was less than 100 percent. If the combined evaluation for all disabilities due to multiple sclerosis is 20 percent or less, assign a 30 percent evaluation under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_124a.DOC"38 CFR 4.124a, DC 8018. Important: Rerate cases previously rated as a single disability as they are encountered under the procedure outlined above.Continued on next page  STYLEREF "Map Title" 26. Multiple Sclerosis, Continued  PRIVATE INFOTYPE="CONCEPT"  c. Example of Rating Residual Disability 30 Percent or MoreThis exhibit contains an example of rating a residual disability 30 percent or more. Coded Conclusion:1. SC (KC PRES)8018-7512 40% from 12-10-81Multiple sclerosis with bladder dysfunction8521 10% from 12-10-81Weakness of right lower extremity secondary to multiple sclerosis8521 10% from 12-10-81Weakness of left lower extremity secondary to multiple sclerosis7523 0% from 12-10-81Impotency without penile deformity, secondary to multiple sclerosisCOMB:50% from 12-10-81 43. Bilateral Factor of 1.9% added for diagnostic codes 8521 and 8521 K-1Entitled to special monthly compensation under 38 U.S.C. 1114, subsection (k) and 38 CFR 3.350(a) on account of loss of use of a creative organ from 12-10-81. Note: SMC coding is 01-01-00-00-1.  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