With each set of proposed changes, the VA
allows a period in which comments can be submitted. The VA then takes each
comment into consideration and makes any additional changes that are warranted
before publishing the final ruling.
We encourage you to submit any comments you
might have on these proposed changes to us either by commenting on this post or
by contacting us through our website. All comments must be received by
September 21, 2015. We will then compile all of your comments into a single report
and submit it on your behalf to the VA, just as we did for the Female Reproductive System. This is a great opportunity to really make a difference,
so please do let us know your thoughts.
The following are the VA’s proposed changes
to the ratings for the Hemic and Lymphatic Systems. The changes are fairly
extensive, so I’ll walk through each, one at a time.
For each condition, the small, indented
parts are the code as it is right now. Click on the code numbers to be taken to
the discussion of that code on our site. After the current code, I’ll discuss
the proposed changes.
The first proposed change is to update the
title of this section from “Hemic and Lymphatic Systems” to “Hematologic and
Lymphatic Systems.” Basically, the term “hemic” is a very general label for
conditions of the blood, and is not used in modern medical terminology as much
anymore. Instead, “hematologic” is the preferred term for conditions of the
blood and the organs directly affecting the blood.
Now on to the codes.
________________________________________________________________________
Code 7700: Anemia that is
caused by low levels of iron or B12 in the body is rated under this
code. This condition is rated based on the amount of hemoglobin in the blood
and symptoms directly related to it. If the anemia causes other complications,
like dementia or neuropathy, that are not rated under this code, then those
conditions can be rated separately.
The normal hemoglobin level for an adult female is 12
to 16 grams per 100 milliliters of blood (g/dL). For an adult male it is 13.5 –
17.5 g/dL. If the hemoglobin level in the blood is 5 g/dL or less and causes
symptoms like difficulty breathing or congestive heart failure, then it is
rated 100%. If the hemoglobin level is 7 g/dL or less and causes symptoms like
difficulty breathing, an enlarged heart, high blood pressure, or fainting (at
least 3 times in the last 6 months), then it is rated 70%. If the hemoglobin
level is 8 g/dL or less and causes symptoms like weakness, headaches, fatigue,
lightheadedness, or shortness of breath, then it is rated 30%. If the hemoglobin
level is 10 g/dL or less and causes symptoms like weakness, fatigue or
headaches, then it is rated 10%. If the hemoglobin level is 10 g/dL or less but
does not cause any symptoms, then it is rated 0%.
It is important to note that these ratings are based
on the hemoglobin level and the symptoms. After the hemoglobin level for
each rating, it says “or less,” meaning that if the condition has an enlarged
heart (rated 70%) and the hemoglobin level is 5gm/100ml (rated 100%), then the
rating would only be 70% since the hemoglobin level for 70% states 7gm/100ml or
less. Regardless of how low the hemoglobin level is, the rating can only go
up if the symptoms support it. On the contrary, if the hemoglobin level is
higher than the requirement for a particular rating, then it cannot receive a
lower rating. For example, if the hemoglobin level is 8gm/100ml (rated 30%) and
there is an enlarged heart (rated 70%), the rating would only be 30% since the
hemoglobin level is too high for the 70% rating. Finally, if there is a
significant heart condition, but only mild anemia, then the condition is only
rated on the heart condition under a heart code.
Okay, a lot is
happening with anemia. Currently, there are three codes for anemia: this one,
code 7714 for sickle cell anemia, and code 7716 for aplastic anemia. Codes 7714
and 7716 will still remain, but the VA proposes that this code (7700) be
removed and four new codes added in its place.
Before discussing the
new codes, I want to explain the VA’s reasoning behind these changes.
Basically, the majority of cases of anemia are either
hereditary or caused by
another condition, like
hypothyroidism. If the anemia is caused by another
condition, then only that other condition should be rated. The anemia is just
considered a symptom of that condition, and thus is covered under a rating for
that condition.
The only time anemia
should be given its own rating is when it is not directly caused by another ratable
condition, or is caused by one of the circumstances addressed by the new codes.
The VA proposes adding these four new codes for anemia in order to better break
down and classify the type and severity of the ratable anemia. Each code covers
a different type of chronic anemia (anemia that has a gradual onset and lasts
over a long period of time), as opposed to acute anemia (anemia directly caused
by a traumatic or extreme event, like internal bleeding). Acute anemia should
be rated under the condition that caused it.
-New Code-
-Proposed- Code
7720: Iron deficiency anemia is
a type of anemia caused by low levels of iron in the blood. If the low levels
of iron are caused by blood loss, then it is not rated under this code, but
under the condition causing the blood loss.
If the anemia requires iron infusions directly into the veins 4 or more
times a year, then it is rated 30%. If it requires you to continuously take high
doses of iron supplements, it is rated 10%. If it doesn’t cause any symptoms or
can be easily controlled by diet, then it is rated 0%.
This one is pretty
straightforward. Not really much to discuss.
-New Code-
-Proposed- Code 7721: Folic acid deficiency anemia is caused by low levels of folic acid
in the blood. If it requires you to continuously take high doses of folic acid
supplements, it is rated 10%. If it doesn’t cause any symptoms or can be easily
controlled by diet, then it is rated 0%.
Folic acid deficiency is very rare these
days, but when it does occur, it is very easily treated by supplements and
diet. Again, pretty straightforward.
-New Code-
-Proposed- Code 7722: Vitamin B12 deficiency anemia (including pernicious anemia) is any type of
anemia caused by low levels of vitamin B12 in the blood. This type of anemia is difficult to detect
early because the liver stores a lengthy supply of B12, so symptoms
do not usually develop until after this supply is depleted.
If the anemia is
severe enough upon diagnosis that it requires a blood transfusion, then it is
rated 100% while being treated and for the first 6 months following discharge
from the hospital. A 100% rating is also given if the anemia causes nervous
system conditions (like myelitis) and requires injections or
IV-administered B12. This 100% rating also continues for the first 6
months following the last B12 treatment. In both cases, after the
6-month mark, the VA will re-evaluate the condition. It will then be given a
10% rating under this code, and any additional symptoms, like myelitis, will be
rated separately.
If the condition
is not severe enough to warrant a 100% rating, but does require continuous
treatment with B12, either by mouth, injection, or nasal sprays, it
is rated 10%.
B12 is an important factor in
the creation of new red blood cells, and so any deficiency of B12 in
the body will directly affect the level of red blood cells, thus leading to
anemia. Any type of B12 deficiency is to be rated under this code,
regardless of the cause of the deficiency.
-New Code-
-Proposed- Code 7723: Acquired hemolytic anemia is caused by the abnormal breakdown of
red blood cells. “Acquired” means that the anemia is the direct result of a
factor like medications, injury, toxic chemicals, etc.
If it requires a
bone marrow transplant, continuous IV treatment, or continuous immunosuppressive
therapy (prednisone, etc.), then it is rated 100%. For bone marrow transplants,
this 100% rating will continue for the first 6 months following discharge from
the hospital. The VA will then re-evaluate the condition and rate it based on
any remaining symptoms or treatment needs.
If it requires
immunosuppressive medication 4 or more times a year, it is rated 60%. If it
requires immunosuppressive medication 2 to 3 times a year, it is rated 30%. If
it requires immunosuppressive medication once a year, it is rated 10%. If it
does not cause any symptoms, it is rated 0%.
If the anemia is
caused by the spleen being completely or partially removed, then the spleen is
rated separately under code 7706 in addition to a rating under this code.
It’s important to note that only acquired hemolytic anemia can be rated
under this code. “Acquired” means that it was not caused naturally or by an
underlying condition. If it was caused by an underlying condition, then just
that underlying condition would be rated. In this case, “acquired” means that another,
separate force caused the anemia. This outside force could include things like
chemicals, medications used to treat other conditions (this would not be
considered an underlying condition since it was the medication, not the
condition itself, that caused the anemia), injuries (for example, prosthetic
heart valves could cause damage to the heart that could lead to anemia), etc.
__________________________________________________________________________
Code 7702: Agranulocytosis (also
known as granulopenia and agranulosis) is a condition where the
bone marrow does not produce enough white blood cells. This significantly
decreases the body’s immune system and makes the body very vulnerable to
infection and disease. If the condition requires a bone marrow transplant, it
is rated 100%. This 100% rating continues for 6 months following the
transplant. The condition will then be reevaluated and re-rated.
Whether or not a transplant is performed, if the
condition requires a transfusion of platelets or red blood cells at least once
every 6 weeks, or if infections occur at least once every 6 weeks, it is rated
100%. If a transfusion or an infection occurs at least once every 3 months,
then it is rated 60%. If a transfusion or an infection occurs at least once a
year, then it is rated 30%. If the condition at least requires continuous
medication, then it is rated 10%.
-Proposed- Code 7702: Agranulocytosis (also
known as granulopenia and agranulosis) is a condition where the
bone marrow does not produce enough white blood cells. This significantly
decreases the body’s immune system and makes the body very vulnerable to
infection and disease.
A few important things to know before getting into the ratings: Neutrophils
are a type of white blood cell that are essential to the immune system. There
are two main different types of treatment that can be used to maintain an
acceptable level of neutrophils in the blood. In medical reports, this will be
noted as the ANC (absolute neutrophil count), and will include a volume count
in microliters (µl), for example, ANC = 750/µl.
One type of treatment used to keep the ANC up is myeloid growth factors.
These are agents that help produce blood cells. The most common myeloid growth
factors are granulocyte colony-stimulating factor (G-CSF) and
granulocyte-macrophage colony-stimulating factor (GM-CSF). The second most
common type of treatment used to boost the ANC is immunosuppressive
therapy—basically drugs, like cyclosporine, that suppress the immune system.
Now the ratings:
If the condition requires a bone marrow transplant, it is rated 100%.
This 100% rating continues for 6 months following the transplant. The condition
will then be reevaluated and re-rated based on any remaining symptoms.
Whether or not a transplant is performed, if infections occur at least
once every 6 weeks each year on average, it is rated 100%.
If continuous
immunosuppressive therapy or intermittent
myeloid growth factors are needed to keep the ANC between 500/µl and 1,000/µl, or
if an infection occurs at least once every 3 months each year on average, then
it is rated 60%.
If intermittent myeloid growth factors are needed to keep the ANC above
1,000/µl, or if an infection occurs at least once a year on average,
then it is rated 30%.
If intermittent myeloid growth factors are needed to keep the ANC at
1,500/µl or above, or if the condition at least requires continuous
medication, like antibiotics, then it is rated 10%.
For a while, transfusions were the popular
treatment option for agranulocytosis, but they have always been somewhat
controversial because of the numerous complications that could arise from them.
Today, transfusions are only really used in particularly severe or unique
cases. Instead, other forms of treatment have been developed that better help
control the symptoms while decreasing the amount and severity of side effects.
The VA’s proposed changes better reflect modern treatment practices and allow
for the proper rating of agranulocytosis in the absence of transfusions.
_________________________________________________________________________
Code 7703: Leukemia is a cancer
of the blood or bone marrow that causes the over-production of immature white
blood cells. There are many different kinds of leukemia, but all are rated the
same. If it is active and undergoing treatment, then it is rated 100%. This
100% rating continues for 6 months after the last treatment. Then the condition
will be reevaluated and re-rated. If the leukemia is not active or being
treated, then it is rated as anemia or aplastic anemia, whichever gives the higher
rating. The final code would look like this: 7703-7700. The first four-digit
code defines the condition as leukemia, and the second four-digit code says
that it is rated as anemia.
-Proposed- Code
7703: All leukemia except myelogenous
leukemia is rated under this code. Leukemia is a cancer
of the blood or bone marrow that causes the over-production of immature white
blood cells. If it is active and undergoing treatment, then
it is rated 100%. This 100% rating continues for 6 months after the last
treatment. Then the condition will be reevaluated and re-rated based on any
lasting symptoms or other conditions caused by the leukemia or the treatment.
If the leukemia is chronic lymphocytic leukemia or monoclonal B-cell
lymphocytosis, it is rated as all other leukemias unless it is in the first
stage (Rai Stage 0) and there are no symptoms. Even when active, chronic
lymphocytic leukemia in Rai Stage 0 does not cause any symptoms and so is rated
0%.
A few changes happened
to the ratings for leukemia. First, the VA decided to separate out chronic
myelogenous leukemia and give it its own code, 7719, since it provides some
unique problems. I’ll discuss the new code 7719 below.
Since leukemia can
cause a lot of problems throughout the body, not just anemia, the VA also
proposes getting rid of the requirement to just rate inactive leukemia on
anemia. Instead, any symptoms or conditions, whether anemia or no, can be rated
separately under these changes.
Finally, chronic
lymphocytic leukemia in its early stages does not cause any symptoms and thus
doesn’t cause a disability. It is only after it progresses to more severe
stages that a true disability appears. If detected early and properly treated,
this leukemia can stay asymptomatic for many years. Thus, until it develops to
a point where symptoms are manifest, the VA proposes that it should only be
rated 0%.
__________________________________________________________________________
Code 7704: Polycythemia vera is
the opposite of anemia. Instead of having too few red blood cells, the bone
marrow produces too many red blood cells. This can cause shortness of breath,
bleeding, dizziness and many serious symptoms. If this condition causes a
serious side effect like high blood pressure, gout, a stroke or a blood clot,
then those conditions are rated separately. They must be serious enough to
cause a significant decrease in the ability to function in order to qualify for
a rating. For example, slightly high blood pressure that does not limit the
amount of activity a person can do is not enough for high blood pressure to be
rated separately.
Polycythemia vera is not curable but can be treated.
If it requires treatment of myelosuppressants then it is rated 100%. This 100%
rating continues for 3 months following the last myelosuppressant treatment.
The condition is then reevaluated and re-rated.
Whether or not myelosuppressants were used, if the
condition is severe enough that a phlebotomy has to be routinely performed,
then it is rated 40%. If the condition is stable whether or not medication is
being taken, then it is rated 10%.
-Proposed- Code
7704: Polycythemia vera is the opposite of anemia. Instead of having
too few red blood cells, the bone marrow produces too many red blood cells.
This can cause shortness of breath, bleeding, dizziness and many serious
symptoms. If this condition causes a serious side effect like high blood
pressure, gout, a stroke or a blood clot, then those conditions are rated
separately. They must be serious enough to cause a significant decrease in the
ability to function in order to qualify for a rating. For example, slightly
high blood pressure that does not limit the amount of activity a person can do
is not enough for high blood pressure to be rated separately.
Polycythemia vera is not curable but can be treated. If it requires a peripheral blood or bone
marrow stem-cell transplant, treatment with radioactive phosphorus, or treatment
with chemotherapy (including myelosuppressants), then it is rated 100%. This
100% rating continues for 6 months following the last treatment or discharge
from the hospital. The condition is then reevaluated and re-rated.
If it requires a phlebotomy to be performed 6 or more times each year, or
if it requires radioactive phosphorus treatments, chemotherapy, or treatment
with other targeted agents (like imatinib or ruxolitinib), then it is rated 60%.
If it requires a phlebotomy to be performed 4 to 5 times each year, or
if it requires continuous therapy (with biologic or myelosuppresive agents) to
keep the platelet count under 200,000 or the white blood cell count under
12,000, then it is rated 30%.
If it requires a phlebotomy or other treatments 3 or less times each
year, then it is rated 10%.
If the condition turns into leukemia, then it is rated as leukemia under
code 7703.
There are many more
standard types of treatments for Polycythemia vera now, so the VA’s proposed
changes are meant to better reflect the severity of the condition based on the
variety of treatments currently used. There is a problem with their proposed
changes, however, that we are definitely going to comment on and hopefully get
fixed. The requirement of radioactive phosphorus or chemotherapy treatments is
listed exactly the same under two different ratings: 60% and 100%. How, then,
are the
Rating Authorities supposed to decide between the two ratings? If it
qualifies for a 100%, then a 60% would never be given. Why give a lower rating
when it qualifies for a higher? They definitely need some clarification of what
they really intended for the different rating levels.
__________________________________________________________________________
Code 7705: Thrombocytopenia is a
condition where the platelet count in the blood is low. The normal amount of
platelets in a microliter of blood is between 150,000 to 450,000. If the
platelet count is less than 20,000 and there is bleeding that requires
medication and transfusions, then it is rated 100%. If the count is between
20,000 and 70,000 but there is no bleeding and it does not require treatment,
then it is rated 70%. If the platelet count is stable and between 70,000 and
100,000 and there is no bleeding, then it is rated 30%. A stable count of
100,000 or more with no bleeding is rated 0%.
-Proposed- Code
7705: Thrombocytopenia is a condition where the platelet count in
the blood is low. The normal amount of platelets in a microliter of blood is
between 150,000 to 450,000.
If the platelet count remains at 30,000 or less despite treatment, it is
rated 100%. A 100% rating is also given if the condition is chronic refractory
thrombocytopenia (a specific type of thrombocytopenia) and it requires
chemotherapy. This 100% rating continues for 6 months following the last
chemotherapy treatment and is then reevaluated and re-rated based on any
remaining symptoms.
A 70% rating is given if the condition requires immunosuppressive
therapy to keep the platelet count between 30,000 and 50,000, and the
patient had been hospitalized at least once in the past for severe bleeding
that was treated with immune globulin, corticosteroids, and platelet transfusions.
A 30% rating is given if the platelet count is between 30,000 and
50,000, and there is mild bleeding that requires either oral corticosteroids
or immune globulin injections.
A 10% rating is given if the platelet count is between 30,000 and
50,000, but no treatment is required.
A 0% rating is given if the platelet count is above 50,000, or if the
immune thrombocytopenia is in remission.
If a splenectomy is performed, it is rated separately under code 7706.
The proposed changes
to the ratings for thrombocytopenia are mostly based on the need to better
reflect the true disability resulting from this condition and to acknowledge
the more modern treatment methods.
_______________________________________________________________________
Codes
7706 and
7707 for conditions of the spleen and splenectomies are
remaining exactly the same.
_______________________________________________________________________
Code 7709: Hodgkin’s
disease is a cancer of the white blood cells (lymphoma) that spreads across
the lymph nodes. Hodgkin’s disease is “staged” based on the severity of the
cancer. The military will usually place the individual with a lower stage
cancer on TDRL and
may place him back on active duty after treatment. An individual with a more
severe cancer will usually be medically retired.
If the cancer is active or
undergoing treatment, then it is rated 100%. This rating continues for 6 months
following the last treatment. The condition is then reevaluated and re-rated
based on the ongoing symptoms.
The only change to
this code is to change the name from “Hodgkin’s disease” to “Hodgkin’s
lymphoma”, the name more widely used now. Everything else is exactly the same.
_________________________________________________________________________
No changes are being made to
code 7710 for tuberculous adenitis.
_________________________________________________________________________
-New Code-
-Proposed- Code
7712: Multiple myeloma is a type
of cancer that creates abnormal plasma cells, a type of white blood cell. These
abnormal cells can build up and form tumors mostly in the bones, but can build
up in the organs as well, thus causing numerous different symptoms. While
multiple myeloma is incurable, it is treatable.
Smoldering or indolent myeloma is the benign precursor to multiple
myeloma and is normally symptom-free. It is thus given a 0% rating. The
majority of cases of smoldering or indolent myeloma do develop into multiple
myeloma, and thus should be carefully monitored. As soon as it can be
officially diagnosed as multiple myeloma, its rating can be increased.
The VA is very specific about the qualifications that must be in place
before any case of myeloma can be officially diagnosed for rating purposes.
For smoldering or indolent myeloma, there must be at least one of the
following:
- a serum monoclonal protein (IgG or IgA) level greater than 30g/L
- a urine monoclonal protein level greater than 500 mg/24 hours
- a clonal bone marrow plasma cell level between 10% and 60%
For active multiple myeloma, there must be both of the following:
- an elevated serum or urine monoclonal protein level
- a clonal bone marrow plasma cell level great than 10%
AND there must be one or more of the following
as evidence of organ tissue damage caused by the build up of plasma cells:
- a serum calcium level greater than or equal
to 11.5mg/100mL
- renal insufficiency with a creatinine
clearance less than 40cc/min or a serum creatinine greater than 1.73 mmol/L
- normochromic or normocytic anemia with a hemoglobin
level less than 11.5g/dL for men and 10.0g/dL for women
- bone fractures, severe osteopenia, or
osteolytic lesions shown by radiographic evidence
In the absence of an elevated serum or urine
monoclonal protein level, then the presence of one or more of the following is
enough to diagnose multiple myeloma:
- a clonal bone marrow plasma cell level equal
to or greater than 60%
- a serum free light chain ratio equal to or
greater than 100
- a free light chain equal to or greater than
100mg/L
- two or more bone lesions greater than 5mm in
size as shown on an MRI
Active, diagnosed multiple myeloma is rated
100%. This 100% rating continues for 5 years after diagnosis. The condition is
then reevaluated by the VA and re-rated as needed.
There
is currently not a code that sufficiently covers and rates multiple myeloma.
The addition of this code will allow for more appropriate and precise ratings
for this condition.
________________________________________________________________________
Code 7714: Sickle cell anemia is
a kind of anemia where the red blood cells that carry the oxygen become shaped
like a sickle (or a boomerang). Because of this, they are not able to carry as
much oxygen to the body, and they sometimes get stuck in small blood vessels,
blocking the blood flow to the tissues. A diagnosis of this condition alone is
not enough to get a rating. There must be proof of significant symptoms that
limit your ability to function in some way. This condition is genetic, and so
it technically did exist prior to service (EPTS), and may not be ratable by
the DoD.
If there are regular severe
painful episodes, blood clots, and other symptoms that all cause the condition
to be severe enough that even light manual labor cannot be performed, then it
is rated 100%. If there are severe painful episodes multiple times a year with
symptoms that restrict activity to just light manual labor, then it is rated
60%. If there have been episodes of severe active destruction of red blood
cells and these episodes cause symptoms that continue after the episode is
over, then it is rated 30%. If the condition has been properly diagnosed and it
affects some organs, but there are no symptoms, then it is rated 10%.
-Proposed- Code 7714: Sickle cell anemia is
a kind of anemia where the red blood cells that carry the oxygen become shaped
like a sickle (or a boomerang). Because of this, they are not able to carry as
much oxygen to the body, and they sometimes get stuck in small blood vessels,
blocking the blood flow to the tissues. A diagnosis of this condition alone is
not enough to get a rating. There must be proof of significant symptoms that
limit your ability to function in some way. This condition is genetic, and so
it technically did exist prior to service (EPTS), and may not be ratable by the DoD.
If there are 4 or more severe painful episodes
each year, with blood clots, anemia, and other symptoms that all cause the
condition to be severe enough that even light manual labor cannot be performed,
then it is rated 100%. If there are 3 or more severe painful episodes each year
with symptoms that restrict activity to just light manual labor, then it is
rated 60%. If there are 1 or 2 severe painful episodes each year, then it is
rated 30%. If the condition has been properly diagnosed and it affects some
organs, but there are no symptoms, then it is rated 10%.
The
only real change to this code is to specify the number of severe episodes that
must occur each year to qualify under a particular rating. This makes it easier
to clearly make rating decisions for cases of sickle cell anemia.
_________________________________________________________________________
Code 7715: Lymphomas that are
not Hodgkin’s are rated under this code. Lymphomas are the growth of lymphoid
cells in areas they are not meant to be. If the cancer is active or undergoing
treatment, then it is rated 100%. This rating continues for 6 months following
the last treatment. It is then reevaluated and re-rated based on the ongoing
symptoms.
-Proposed- Code
7715: Lymphomas that are not Hodgkin’s are rated under this code.
Lymphomas are the growth of lymphoid cells in areas they are not meant to be.
If the cancer is active—even if it is only in an indolent, slow growth, or
non-contiguous stage—or undergoing treatment, then it is rated 100%. This
rating continues for 2 years following the last treatment. It is then
reevaluated and re-rated based on the ongoing symptoms.
Two
changes were made to this code. First, additions were added to clarify that
even the lowest stage of non-Hodgkin’s lymphomas are rated at 100%, not just
the more aggressive stages. Second, the 100%-rating period was changed from 6
months to 2 years because lymphomas are notorious for recurring, often after
the 6-month period, but usually within 2 years.
__________________________________________________________________________
Code 7716: Aplastic anemia is a
condition where the bone marrow does not make enough new blood cells. If the
condition requires a bone marrow transplant, then it is rated 100%. This 100%
rating will continue for 6 months following the transplant surgery. After this
time, the condition will be reevaluated and rated on its need for continuing
transfusions or medications as detailed below.
If the condition does not need
a transplant, but requires a transfusion of red blood cells or platelets at
least once every 6 weeks or if there are infections that occur at least
every 6 weeks, then it is rated 100%. If it requires a transfusion at least
once every 3 months or if there are infections occurring every 3 months,
then it is rated 60%. If it requires a transfusion at least once a year or
if there are infections occurring at least once a year, then it is rated 30%.
If the condition at least requires continuous medication, then it is rated 10%.
-Proposed- Code
7716: Aplastic anemia is a condition where the bone marrow does not
make enough new blood cells. If the condition requires a bone marrow or
peripheral blood stem cell transplant, then it is rated 100%. This 100% rating
will continue for 6 months following discharge from the hospital. After this
time, the condition will be reevaluated and re-rated.
If the condition does not need a transplant,
but requires a transfusion of red blood cells or platelets at least once every
6 weeks each year on average or if there are infections that occur at
least every 6 weeks each year on average, then it is rated 100%.
If it requires a transfusion at least once
every 3 months each year on average, or if there are infections
occurring every 3 months each year on average, or if it requires
continuous immunosuppressive therapy, then it is rated 60%.
If it requires a transfusion at least once a
year on average, or if there are infections occurring at least once a
year on average, then it is rated 30%.
The
VA proposes to update this code to better reflect current treatments of
aplastic anemia, including peripheral blood stem cell transplants. Also the
terms “on average” were added to better standardize the rating options. Finally,
the VA proposes to get rid of the 10% rating altogether, stating that any
medications used to treat aplastic anemia qualify for a higher rating, and so
the 10% rating is now obsolete. This is further justified by the fact that they
added the requirement of immunosuppressive therapy to the 60% rating, thereby
covering all the standard treatment options under the higher ratings.
_________________________________________________________________________
-New Code-
-Proposed- Code
7718: Essential thrombocythemia
is a disease which causes the body to produce too many platelets, and primary myelofibrosis is a condition
that interferes with the ability of the bone marrow to produce blood cells,
thus resulting in abnormal cell and platelet levels. Both are rated under this
code.
If the condition requires a bone marrow or
peripheral blood stem cell transplant or radioactive phosphorus or
chemotherapy (including myelosuppresants), it is rated 100%. This 100% rating
continues for 6 months following discharge from the hospital or following the
last treatment. It is then reevaluated and re-rated by the VA.
A 100% rating is also given for the entire time
the condition requires continuous myelosuppressive therapy. If the condition
requires myelosuppressive therapy to keep the platelet count less than 500,000,000,000/L
(a.k.a. 500x109/L), it is rated 70%. If it requires myelosuppressive
therapy to keep the platelet count between 200,000 and 400,000 or to keep the
white blood cell count between 4,000 and 10,000, it is rated 30%. A 0% rating
is given if the condition is asymptomatic.
If the condition turns into leukemia, it is
then not rated under this code, but under code 7703.
This
is a new code the VA is proposing to cover one of the myeloproliferative
disorders (conditions that cause the overproduction of either white blood
cells, red blood cells, or platelets) that have previously not been included in
the VASRD. A different code is proposed to cover each of the types of
overproduction: 7704 for overproduction of red blood cells (not a new code, but
adjusted), 7718 for overproduction of platelets, and 7719 for overproduction of
white blood cells.
Although
7718 is technically for overproduction of the platelets (essential
thrombocythemia), it also includes primary myelofibrosis. This is a bit odd
since primary myelofibrosis does not cause the overproduction of platelets in
the majority of cases. It is far more like to cause the overproduction of white
blood cells. So, exactly why the VA decided to include it under this code is
not clear. It would be far less confusing to the Rating Authorities to give
primary myelofibrosis its own code or rate it under 7719. We’ll comment on it,
and see what they ultimately decide.
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-New Code-
-Proposed- Code
7719: Chronic myelogenous leukemia
(a.k.a. CML, chronic myeloid leukemia, or chronic granulocytic leukemia) is a
cancer that causes the bone marrow to produce too many white blood cells. It is
a form of leukemia, but because of its unique properties, there are different
treatment options. CML can evolve into regular leukemia. If it does, then it is
rated under code 7703 for all other leukemias.
If the condition requires a bone marrow or
peripheral blood stem cell transplant or if it requires continuous
myelosuppressive or immunosuppressive therapy (like radioactive phosphorus or
chemotherapy), then it is rated 100%. This 100% rating continues for 6 months
following the last treatment or discharge from the hospital. The condition is
then reevaluated by the VA and re-rated.
If the condition requires interferon
treatments, periodic myelosuppressive therapy, or tyrosine kinase inhibitor
therapy, it is rated 60%. If the condition requires continuous tyrosine kinase
inhibitor therapy to keep it in apparent remission, it is rated 30%.
The
VA proposes to add this code and separate the rating of chronic myelogenous leukemia
from the rating of all other leukemias (code 7703). This separation is due
primarily to the fact that CML can often be treated effectively by modern
medications and treatments, thus keeping the seriousness of the condition at
bay in many instances. Because of this, there are varying severities of CML
that can last for significant periods of time, thus requiring appropriate
ratings for the varying severities.
_________________________________________________________________________
-New Code-
-Proposed- Code
7724: Solitary plasmacytoma is a
cancer of the plasma cells that develops in the bones. If caught early, the
majority of solitary plasmacytomas are curable, but the majority can also turn
into multiple myeloma. If the plasmacytoma develop into multiple myeloma, then
it is rated under code 7712 as symptomatic multiple myeloma.
Treatments for solitary plasmacytoma can
include surgery, radiation, chemotherapy, stem cell transplants, and other
procedures.
If the solitary plasmacytoma is active or being
treated, it is rated 100%. The 100% rating continues for 6 months following the
last treatment. The VA will then reevaluate and re-rate the condition. If the
condition or its treatments cause other conditions, like
thrombosis or
nerve damage,
then each can be rated separately.
Like
the previous code, the VA proposes giving solitary plasmacytoma its own code
instead of rating it as multiple myeloma since it can be treated and even
cured.
_________________________________________________________________________
-New Code-
-Proposed- Code
7725: Myelodysplastic syndromes
are conditions in which the body does not produce enough of all types of blood
cells. If the condition requires a bone marrow or peripheral blood stem cell
transplant, or if it requires chemotherapy, it is rated 100%. This 100% rating
continues for 6 months following the last treatment or discharge from the
hospital. It will then be reevaluated and re-rated by the VA.
If the condition requires 4 or more blood or
platelet transfusions each year on average, or if it causes 3 or more
infections that require hospitalization each year on average, it is rated 60%.
If the condition requires 1 to 3 blood or
platelet transfusions each year on average, or if it causes 1 or 2
infections that require hospitalization each year on average, or if it
requires either ongoing interferon alpha therapy or erythropoiesis stimulating
agent (ESA) for 12 weeks or less, it is rated 30%.
If the condition develops into leukemia, it is
rated under code 7703.
The
VA proposes adding this code because myelodysplastic syndromes are fairly
common in veterans, and the VASRD does not currently have a code that
satisfactorily rates the treatment needs of these disorders.