General Considerations for Rating

• Rating coexisting respiratory conditions.

  M21-1 Part III, Subpart iv, Chapter 4, Section D.1.g Ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. However, in cases protected by the provisions of Pub. L. 90-493, the graduated ratings of 50 and 30 percent for inactive tuberculosis will not be elevated. 38CFR §4.96 [Special provisions regarding evaluation of respiratory conditions]. [M21-1 Part III, Subpart iv, Chapter 4, Section D]

  When the results of pre-bronchodilator pulmonary function tests are normal, post-bronchodilator studies are ordinarily not done and are not required for VA evaluation purposes. In all other cases, post-bronchodilator studies should be done unless contradicated (because of allergy to medication, etc.) or if a patient was on bronchodilators before the test and had taken his or her medication within a few hours of the study. An examiner who determines that a post-bronchodilator study should not be done in a given case should provide an explanation. You should request this explanation if it is not provided (unless the pre-bronchodilator results are normal). [M21-1 Part III, Subpart iv, Chapter 4, Section D]

• Post-bronchodilator results.

  When available, the post-bronchodilator results should always be used in applying the evaluation criteria in the rating schedule. There is, however, a small group of patients (5% or less), in whom for unknown reasons there may be a paradoxical reaction to bronchodilators, i.e., the post-bronchodilator results will be poorer than the pre-bronchodilator results. When there is a paradoxical response, you should use the better (pre-bronchodilator) values.

  When there is disparity between the results of different tests (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result you use, the examiner should tell you which test result most accurately reflects the level of disability. Request this information from the examiner if he or she has not provided it.

  When the FEV-1 is greater than 100% , an Fev-1/FVC ratio that is below normal should be considered a physiologic variant rather than an abnormal value.