M21-1 Manual / Part V, Subpart iii, Chapter 4, Section A

Respiratory Conditions

M21-1, Part V, Subpart iii, Chapter 4, Section A

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	Basic Rating Principles for Respiratory Conditions
2	Sleep Apnea and Related Disabilities
3	Respiratory Tract Infections
4	Other Respiratory Disorders

1. Basic Rating Principles for Respiratory Conditions

Introduction

This topic contains basic rating principles for respiratory conditions, including

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
requirement for pulmonary function tests (PFTs)
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.

Change Date

April 18, 2018

V.iii.4.A.1.a. Prohibition of 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 V, Subpart ii, 3.D.2.b, and
Esteban v. Brown, 6 Vet.App. 259 (1994).

V.iii.4.A.1.b. 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
that 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 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 for instructions on proper application of the 38 CFR 4.96(a) provision on assigning an evaluation in cases of multiple qualifying coexisting respiratory disabilities.
Step Action
1 Determine which of the coexisting respiratory conditions is the predominant disability. Important:
To determine the predominant disability, determine the evaluation each condition would 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 coexistent 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.
Reference: For more information on application of 38 CFR 4.96(a), see Urban v. Shulkin, 29 Vet.App. 82 (2017).

V.iii.4.A.1.c. 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.

V.iii.4.A.1.d. Example 2 - Evaluating Coexisting Respiratory Disabilities

Situation: Asbestosis (38 CFR 4.97, DC 6833) warrants an evaluation of 30 percent based on diffusion capacity of the lung for carbon monoxide (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 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.

V.iii.4.A.1.e. Requirement for PFTs

PFT results are required for 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845 as specified at 38 CFR 4.96(d) 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.
When the rating criteria for a disability not regulated by 38 CFR 4.96(d) include PFTs among the potential methods for assigning a disability evaluation, such as 38 CFR 4.97, DC 6602 for asthma, PFTs are not required to evaluate the disability. However, if PFTs were previously utilized to assign a disability evaluation and consideration is being given to a reduced evaluation, apply 38 CFR 3.344(a). When the prior evaluation was assigned based on PFTs, the current examination must also include PFTs if a reduced evaluation due to improvement is being considered.

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

V.iii.4.A.1.f. Assigning Disability Evaluations Based on the Results of PFTs

The table below contains instructions for assigning disability evaluations based on the results of PFTs. This table applies to 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845 as specified at 38 CFR 4.96(d).

If …	And …	Then ...
PFTs are not consistent with clinical findings	the examiner doesnot 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.

V.iii.4.A.1.g. Post-Bronchodilator Studies, Requirements, and Evaluations

Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes for disabilities rated under 38 CFR 4.97, DC 6600, 6603, 6604, 6825-6833, and 6840-6845except 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.

V.iii.4.A.1.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. 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

February 19, 2019

V.iii.4.A.2.a. Sleep Apnea and Sleep Studies

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 service connection (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: Accept a home sleep study only 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 on types of medical providers qualified to provide medical evidence, see M21-1, Part IV, Subpart i, 3.A.1.

V.iii.4.A.2.b. 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

whether a device qualifies, as discussed in M21-1, Part V, Subpart iii, 4.A.2.c, and
if use of a qualifying device is necessary, as discussed in M21-1, Part V, Subpart iii, 4.A.2.d.

V.iii.4.A.2.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).

V.iii.4.A.2.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.

V.iii.4.A.2.e. Processing Claims for Increase in Sleep Apnea

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

Step	Action
1	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 X, Subpart ii, 3.D.1.
6	Perform any additional development as necessary, continue SC for sleep apnea, and assign an evaluation based on the evidence of record.

V.iii.4.A.2.f. 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 a supplemental claim may be submited if a clinical diagnosis of sleep apnea is subsequently confirmed.

Example: References: For more information on
subthreshold diagnoses, see M21-1, Part V, Subpart ii, 3.C.1.b
sleep disorders examination review, see M21-1, Part IV, Subpart i, 3.B.1.l, and
using analogous DCs, see
M21-1, Part V, Subpart iv, 1.C.2.a and b, and
M21-1, Part V, Subpart ii, 3.D.1.b.

3. 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

V.iii.4.A.3.a. Types of Chronic Upper Respiratory Tract Infections

Chronic upper respiratory tract infections include

chronic rhinitis
chronic sinusitis
chronic tonsillitis, and
chronic laryngitis.

V.iii.4.A.3.b. 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.

V.iii.4.A.3.c. 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 SC for other conditions first manifest after discharge.Carefully consider the character of the infection and possible intervening causes.

V.iii.4.A.3.d. 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.

4. 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
rhinosinusitis
allergic rhinitis
constrictive bronchiolitis
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

April 22, 2022

V.iii.4.A.4.a. 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.

V.iii.4.A.4.b. Sinusitis

Evaluate sinusitis under 38 CFR 4.97, 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.

V.iii.4.A.4.c. Considering Allergic Rhinitis Within Scope of Claimed Sinusitis

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 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 V, Subpart ii, 3.A.2, and
38 CFR 3.155(d)(2).

V.iii.4.A.4.d. Rhinosinusitis

Rhinosinusitis should be rated as a type of sinusitis, using the general rating formula and choosing the most appropriate DC from 38 CFR 4.97, DC 6510 through 6514. Select the DC for the type of sinusitis that most closely corresponds with the location of the rhinosinusitis. Note:

DC 6599 analogous code indicator should precede the analogous sinusitis DC because rhinosinusitis is not listed in the rating schedule.
Rhinosinutis is a chronic disease associated with exposure to particulate matter, as provided in 38 CFR 3.320(a)(2).

Reference: For more information on claims for SC for chronic diseases associated with exposure to particulate matter, see M21-1, Part VIII, Subpart ii, 2.A-C.

V.iii.4.A.4.e. 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.

V.iii.4.A.4.f. Constrictive Bronchiolitis

Constrictive bronchiolitis (also known as bronchiolitis obliterans) is an inflammatory and fibrotic lesion of the terminal bronchioles of the lungs. Possible causes include

inhalation exposures
organ transplantation
certain drugs, and
collagen vascular disorders.

The following are common findings in constrictive bronchiolitis.

Affected individuals are comfortable at rest and able to perform activities of daily living.
X-rays can be normal.
PFTs can be normal or near-normal.
In spite of normal x-rays and PFTs, the in-service symptoms and complaints often include
- shortness of breath on physical exertion
- inability to meet physical training requirements, and/or
- a finding of unfitness for deployment.
- In some cases, symptoms can be incorrectly attributed to asthma or COPD.
Constrictive bronchiolitis does not have its own DC. Select an appropriate analogous DC, such as 38 CFR 4.97, DC 6600 through 6604, when rating constrictive bronchiolitis. Utilize a built-up, hyphenated DC, such as, 6699-6600, to reflect the use of the analogous rating.
- PFTs are the usual standard for rating respiratory disabilities.
- Consider extra-schedular evaluations in cases where there is evidence that
  - an exceptional or unusual disability picture is present, and
  - a Veteran’s employment is affected.
References: For more information on
- claims for SC for constrictive bronchiolitis associated with exposure to environmental hazards during the Gulf War era, see M21-1, Part VIII, Subpart ii, 3.A and B
- the identification of constrictive bronchiolitis in individuals exposed to environmental hazards associated with the Mishraq state sulfur mine fire, see M21-1, Part VIII, Subpart ii, 3.B.3.c
- extra-schedular evaluations, see M21-1, Part V, Subpart ii, 3.D.3, and
- analogous
  - ratings, see 38 CFR 4.20, and
  - DCs, see 38 CFR 4.27.

V.iii.4.A.4.g. Complete Organic Aphonia and SMC

Award special monthly compensation (SMC) if complete organic aphonia 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 VIII, Subpart iv, 4.A.4.i, and
M21-1, Part VIII, Subpart iv, 4.B.2.g.

V.iii.4.A.4.h. 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.

V.iii.4.A.4.i. 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.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 4, Section A (U.S. government work, reproduced for reference). Browse all sections →