Sorry for the mess!

The site is undergoing a massive update. All the content on the site still works but things just might look a little messy and disorganized. Most of the upgrades will probably be don by the end of the month. Thank you for your understanding!

Updated Feb 15, 2023

In This Section
 This section contains the following topics:
Topic
Topic Name
1
2
3

1.  MS

Introduction
This topic contains information about MS, including

Change Date
April 16, 2020

V.iii.12.C.1.a.   Definition: MS
Multiple sclerosis (MS) 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.

V.iii.12.C.1.b.  Evaluating a Residual MS Disability 30 Percent or More
In cases of MS
  • evaluate each affected system or body part separately
  • show the diagnostic code (DC) for MS 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 MS.
Notes:
  • This is a change from the previous requirement to evaluate MS as a single disability when the combined degree was less than 100 percent.
  • If the combined evaluation for all disabilities due to MS is 20 percent or less, assign a 30-percent evaluation under 38 CFR 4.124a, DC 8018.
Important:  Readjudicate cases previously evaluated as a single disability as they are encountered under the procedure outlined above.

V.iii.12.C.1.c.  Example of Evaluating Residual MS Disability 30 Percent or More
This exhibit contains an example of evaluating a residual MS disability 30 percent or more.
Coded Conclusion:
1. SC (KC PRES)
8018-7542
40% from 12-10-19
Multiple sclerosis with bladder dysfunction
8520
10% from 12-10-19
Weakness of right lower extremity secondary to multiple sclerosis
8520
10% from 12-10-19
Weakness of left lower extremity secondary to multiple sclerosis
7599-7522
0% from 12-10-19
Impotency without penile deformity, secondary to multiple sclerosis
COMB:
50% from 12-10-19
43. Bilateral Factor of 1.9% added for diagnostic codes 8520 and 8520
K-1
Entitled 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 12-10-19.
 
Note:  Special monthly compensation (SMC) coding is 01-01-00-00-1.

V.iii.12.C.1.d. Presumptive SC for MS
Presumptive service connection (SC) may be established for MS if the disease becomes manifest within seven years from the date of separation.
 
Reference:  For more information on requirements for establishment of presumptive SC, see

2.  ALS

Introduction
This topic contains information about ALS, including

Change Date
February 15, 2023

V.iii.12.C.2.a.  Definition: ALS
Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s 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.

V.iii.12.C.2.b.  Establishing Presumptive SC for ALS
Effective September 23, 2008, 38 CFR 3.318 established a presumption of SC for ALS manifested at any time after discharge or release from active military, naval, air, or space service.
 
Exceptions:  SC will not be established if
  • there is affirmative evidence that ALS was
    • not incurred or aggravated by military, naval, or air service, or
    • was due to the Veteran’s own willful misconduct; or
  • if the Veteran did not have active, continuous service of 90 days or more.
In Bowers v. Shinseki, 748 F.3d. 1351 (Fed. Cir., 2014), the Federal Circuit held that active duty for training does not qualify as active military, naval, air, or space service for the purpose of establishing entitlement to SC for ALS on a presumptive basis.
 
Note:  Primary lateral sclerosis (PLS) is not considered to be a qualifying disease under 38 CFR 3.318.  Because PLS and ALS are diseases of the nervous system and both affect motor neurons, treating physicians may not be able to identify whether the Veteran has PLS or ALS in the initial stages.  If the diagnosis is uncertain after reviewing the medical evidence, request a medical opinion with examiner review of all pertinent evidence in the claims folder.
This was considered a liberalizing regulation.  Therefore consider the application of 38 CFR 3.114(a) when granting presumptive SC for ALS under the provisions of 38 CFR 3.318.
 
References:  For more information on

V.iii.12.C.2.c.  Assigning a 100 Percent Minimum Evaluation for ALS
ALS is evaluated under 38 CFR 4.124a, DC 8017.
Effective January 19, 2012, the diagnostic criteria for ALS were amended in 38 CFR 4.124a to provide a 100-percent evaluation for any Veteran with service-connected (SC) ALS.  A diagnosis of ALS alone is sufficient to support an evaluation of 100 percent.  A total disability evaluation is the minimum evaluation to be assigned for ALS because of the possibility of SMC and automatic entitlement to ancillary benefits.
 
Note:  This rule will be applied to all cases pending before VA on or after, January 19, 2012, and does constitute a liberalizing VA regulation under 38 U.S.C. 5110(g) and 38 CFR 3.114 for the purpose of determinations of effective dates and retroactive benefits.

V.iii.12.C.2.d.  Evaluation Guidelines for ALS
Determine the proper evaluation for all complications of ALS prior to coding a single 100-percent evaluation under 38 CFR 4.124a, DC 8017.  Refer to the table below for guidance.
If …
Then …
there is no complication warranting a single 100-percent evaluation
  • assign a 100-percent evaluation under 38 CFR 4.124a, DC 8017, and
  • include all compensable complications in the description of the diagnosis.
Example:  ALS with loss of use of the left foot and partial ninth cranial nerve paralysis.
a single 100-percent evaluation is warranted for a complication of ALS
  • assign a 100-percent evaluation for that complication.
    • Use a hyphenated DC.
    • Example:  8017-5110, loss of use of both feet.
  • Separately evaluate additional complications.
  • Do not assign a separate evaluation under 38 CFR 4.124a, DC 8017 alone; this would be pyramiding under 38 CFR 4.14.
Note:  A 100-percent evaluation for a complication of ALS satisfies the policy that all ALS awards will be assigned at least a 100-percent evaluation.

V.iii.12.C.2.e.   ALS and Ancillary Benefits
Consider eligibility for SMC and/or other ancillary benefits in all ALS cases.
  • Ensure the Codesheet reflects all complications that can be separately evaluated.
  • Entitlement to SMC at the statutory housebound rate may be warranted when
    • ALS and complications are assigned one 100-percent evaluation under 38 CFR 4.124a, DC 8017 and the combined evaluation of other SC conditions totals 60 percent or higher, or
    • an ALS complication is evaluated as 100-percent disabling and the combined evaluation of other SC conditions, including additional separately evaluated complications of ALS, total 60 percent or higher.
  • Entitlement to SMC, such as SMC K for loss of use of a foot, may still be warranted when one total disability evaluation is assigned for ALS and all complications under 38 CFR 4.124a, DC 8017.
  • Effective December 3, 2013, 38 C.F.R. 3.809d provides that SC ALS is a qualifying condition for the purpose of entitlement to specially adapted housing.
  • Effective February 25, 2015, 38 CFR 3.808 provides that SC ALS is a qualifying condition for entitlement to a certificate of eligibility for automobile or other conveyance and adaptive equipment.  The amendment applies to all applications pending before VA on, or received after, February 25, 2015.
References:  For more information on

V.iii.12.C.2.f.  Authority to Decide ALS Claims
All claims involving ALS and/or related complications must be reviewed/rated by a Rating Veterans Service Representative designated as an ALS specialist.

3.  Parkinson’s Disease and Parkinsonism

Introduction

Change Date
June 21, 2021

V.iii.12.C.3.a.  Definition: Parkinson’s Disease
Parkinson’s disease is a chronic, slowly progressive central nervous system disorder characterized by muscular rigidity, a tremor of resting muscles, slow and decreased voluntary movements and positional instability.  An outdated term for Parkinson’s disease is paralysis agitans.
Early signs and symptoms of the condition may include:
  • infrequent blinking
  • lack of facial expression
  • decreased movement, and
  • impaired postural reflexes.
The condition is characterized by muscle tremors at rest which diminish during movement and are absent during sleep.  The tremors are enhanced by emotional tension or fatigue and the hands are most affected. Muscle rigidity may be present without tremors.  As the muscle rigidity progresses, movement becomes slow (bradykinesia), decreased or diminished (hypokinesia), and difficult to initiate (akinesia).  Other signs and symptoms may include:
  • muscular aches and fatigue
  • mask-like expression with open mouth
  • drooling
  • stooped posture
  • gait characterized by involuntary, short, accelerating steps
  • difficulty in walking
  • loss of postural reflexes (tendency to fall forward or backward with respective shift in center of gravity)
  • speech manifestations – specifically low speech volume with stuttering or slurred speech, or uniformity of tone and high pitch, and
  • dysphagia.

V.iii.12.C.3.b. Definition: Parkinsonism
Parkinsonism is a disease process separate and distinct from Parkinson’s disease.  Also called atypical Parkinson’s disease or Parkinson’s plus, it is a general term that refers to a group of neurological disorders that cause movement problems similar to those seen in Parkinson’s disease, as discussed in M21-1, Part V, Subpart iii, 12.C.3.a.

V.iii.12.C.3.c.  SC for Parkinson’s Disease and Parkinsonism
Parkinson’s disease or Parkinsonism can be directly incurred in service, but in most cases, either will be SC on a presumptive or secondary basis.
  • Paralysis agitans is listed as a chronic disease in 38 CFR 3.309(a) and as such Parkinson’s disease is presumed to have had its inception in service if manifested to a compensable degree within one year of discharge under 38 CFR 3.307(a)(3).
  • Parkinson’s disease is listed as a disease associated with exposure to certain herbicide agents in 38 CFR 3.309(e) and therefore is presumed to be related to herbicide exposure in the Republic of Vietnam (RVN) when manifested to a compensable degree at any time after service as provided in 38 CFR 3.307(a)(6) or 38 U.S.C. 1116A.
  • Public Law 116-283, William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021, effective January 1, 2021, established a presumption of SC for Parkinsonism as related to herbicide exposure in the RVN when manifested to a compensable degree at any time after service as provided in 38 CFR 3.307(a)(6) or 38 U.S.C. 1116A.
  • Finally, under 38 CFR 3.310(d), Parkinson’s disease and/or Parkinsonism is treated as secondary to traumatic brain injury (TBI) when the TBI was moderate or severe.
References:  For more information on

V.iii.12.C.3.d.  Evaluating Parkinson’s Disease and Parkinsonism
Evaluate
Use the same rating guidance as for MS as provided in M21-1, Part V, Subpart iii, 12.C.1.b.

V.iii.12.C.3.e. SMC and Parkinson’s Disease/ Parkinsonism
Give careful consideration to SMC in cases of Parkinson’s disease and/or Parkinsonism, particularly losses of use and aid and attendance (A&A).
 
References:  For more information on