Rating Schedule

INTRODUCTION

For the purposes of determining impairment due to disorders of the upper digestive tract, “desirable” weight may be defined as follows:

A. If the examiner is able to determine by history or from previous medical records a weight before onset of the patient’s digestive illness that he or she considers “usual,” the examiner should use that weight as the “desirable” weight from which any deviations are measured.

B. If the examiner is not able to determine by history or from previous medical records a pre-illness “usual” weight, the examiner should refer to a table of “desirable” weights and should determine deviations from the lower end of the range of the “desirable” weight for the patient’s sex, height, and body build. Table 1, which is based on the 1979 Body Build Study by the Society of Actuaries and Association of Life Insurance Medical Directors of America, is recommended.

For an obese patient, the pre-illness weight may not be as physiologically “desirable” as the present weight; thus, the examiner should use judgment in assessing the relative importance of weight loss in determining the impairment rating.

In most cases, the examiner should use the definition shown under A. The definition and reference in B will be helpful if A cannot be used.

UPPER DIGESTIVE TRACT (ESOPHAGUS, STOMACH, DUODENUM, SMALL INTESTINE AND PANCREAS)

Esophagus—Objective procedures useful in establishing impairment include, but are not limited to: (1) fluoroscopy and radiography with contrast materials; (2) peroral endoscopy; (3) cytology and/or biopsy; and (4) manometry.

Stomach and Duodenum—Objective procedures useful in establishing impairment include, but are not limited to: (1) fluoroscopy and radiography with contrast materials; (2) peroral endoscopy; (3) cytology and/or biopsy; (4) gastric secretory tests; (5) assimilation tests; and (6) stool examination.

Small Intestine—Objective procedures useful in establishing impairment include, but are not limited to: (1) fluoroscopy and radiography with contrast materials; (2) peroral mucosal endoscopy; and (3) measures of intestinal assimilation, for example, test for fecal fat excretion and urinary d-xylose excretion, C14 breath test, serum bile determination and Schilling test.

Pancreas—Objective procedures useful in establishing impairment include but are not limited to: (1) radiography including plain or scout films of the abdomen, ultrasonography, CT scan, and endoscopic pancreatography; (2) determination of plasma glucose and glucose tolerance; (3) assay of pancreatic enzyme activity in blood, urine, and feces; (4) sweat electrolyte test; and (5) selected secretory tests such as the secretion test, and cytology.

Classes of Upper Digestive Tract Impairment

Class 1—Impairment of the Whole Person, 1—5%

Symptoms or signs of upper-digestive-tract disease are present or there is anatomic loss or alteration;

and

Continuous treatment is not required;

and

Weight can be maintained at the desirable level;

or

There are no sequelae after surgical procedures.

Class 2—Impairment of the Whole Person, 6—20%

Symptoms and signs of organic upper-digestive-tract disease are present; or there is anatomic loss or alteration;

and

Appropriate dietary restrictions and drugs are required for control of symptoms, signs and/ or nutritional deficiency;

and

Loss of weight below the “desirable weight” does not exceed 10%

Class 3—Impairment of the Whole Person, 21—45%

Symptoms and signs of organic upper-digestive-tract disease are present or there is anatomic loss or alteration;

and

Appropriate dietary restrictions and drugs do not completely control symptoms, signs, and/or nutritional state;

or

There is 10 - 20 pound loss of weight below the “desirable weight,” which is ascribable to a disorder of the upper digestive tract.

Class 4—Impairment of the Whole Person, 46—75%

Symptoms and signs of organic upper-digestive-tract disease are present or there is anatomic loss or alteration;

and

Symptoms are not controlled by treatment;

or

There is greater than a 20 pound loss of weight below the “desirable weight,” which is ascribable to a disorder of the upper digestive tract.

COLON AND RECTUM

Objective procedures useful in establishing impairment of the colon and rectum include, but are not limited to: (1) digital and endoscopic examination including anoscopy, proctoscopy, sigmoidoscopy, and colonoscopy; (2) fecal microscopy and culture; (3) biopsy; and (4) fluoroscopy and radiography with contrast materials.

Classes of Colonic and Rectal Impairment

Class 1—Impairment of the Whole Person, 1—5%

Signs and symptoms of colonic or rectal disease are infrequent and of brief duration;

and

No limitation of activities, special diet, or medication is required;

and

No systemic manifestations are present, and weight and nutritional state can be maintained at a desirable level;

or

There are no sequelae after surgical procedures.

Class 2—Impairment of the Whole Person, 6—20%

There is objective evidence of colonic or rectal disease or anatomic loss or alteration;

and

There are mild gastrointestinal symptoms with occasional disturbances of bowel function accompanied by moderate pain;

and

Minimal restriction of diet or mild symptomatic therapy may be necessary;

and

No impairment of nutrition results.

Class 3—Impairment of the Whole Person, 21—45%

There is objective evidence of colonic or rectal disease or anatomic loss or alteration;

and

There are moderate to severe exacerbations with disturbance of bowel habit, accompanied by periodic or continual pain;

and

Restriction of activity, special diet, and drugs are required during attacks;

and

There are constitutional manifestations (fever, anemia or weight loss).

Class 4—Impairment of the Whole Person, 46—75%

There is objective evidence of colonic or rectal disease or anatomic loss or alteration;

and

There are persistent disturbances of bowel function present at test with severe persistent pain;

and

Complete limitation of activity, continued restriction of diet, and medication do not entirely control the symptoms;

and

There are constitutional manifestations (fever, weight loss, and/or anemia) present;

or

There is no prolonged remission.

ENTEROCUTANEOUS FISTULAS OF THE GASTROINTESTINAL TRACT, BILIARY TRACT, OR PANCREAS

ANUS

Classes of Anal Impairment

Class 1—Impairment of the Whole Person, 1—5%

Signs of organic anal disease are present or there is anatomic loss or alteration;

or

There is mild incontinence involving gas and/or liquid stool;

or

Anal symptoms are mild, intermittent, and controlled by treatment.

Class 2—Impairment of the Whole Person, 6—15%

Signs of organic anal disease are present or there is anatomic loss or alteration;

and

Moderate but partial fecal incontinence is present requiring continual treatment;

or

Continual anal symptoms are present and incompletely controlled by treatment.

Class 3—Impairment of the Whole Person, 16—25%

Signs of organic anal disease are present and there is anatomic loss or alteration;

and

Complete fecal incontinence is present;

or

Signs of organic anal disease are present and severe anal symptoms unresponsive or not amenable to therapy are present.

HEPATOBILIARY SYSTEM

Objective procedures useful in establishing hepatobiliary impairment include, but are not limited to: (1) radiography employing contrast materials, including percutaneous and endoscopic cholangiography, and nuclide scintigraphy; (2) ultrasonography; (3) computerized tomography (CT scan); (4) angiography (5) liver biopsy; and (6) selected laboratory tests to assess various functions of the liver and biliary ducts.

Classes of Liver and Biliary Impairment (Liver Impairment)

Class 1—Impairment of the Whole Person, 1—5%

There is objective evidence of persistent liver disease even though no symptoms of liver disease are present, and no history of ascites, jaundice, or bleeding esophageal varices within 3 years;

and

Nutrition and strength are good;

and

Biochemical studies indicate minimal disturbance in liver function;

or

Primary disorders of bilirubin metabolism are present.

Class 2—Impairment of the Whole Person, 6—20%

There is objective evidence of chronic liver disease even though no symptoms of liver disease are present, and no history of ascites, jaundice, or bleeding esophageal varices within 3 years;

and

Nutrition and strength are good;

and

Biochemical studies indicate more severe liver damage than Class 1.

Class 3—Impairment of the Whole Person, 21—45%

There is objective evidence of progressive chronic liver disease, or history of jaundice, ascites, or bleeding esophageal or gastric varices within the past year;

and

Nutrition and strength may be affected;

or

There is intermittent hepatic encephalopathy.

Class 4—Impairment of the Whole Person, 46—75%

There is objective evidence of progressive chronic liver disease, or persistent ascites or persistent jaundice or bleeding esophageal or gastric varices, with central nervous system manifestations of hepatic insufficiency;

and

Nutritional state is poor.

Classes of Liver and Biliary Impairment (Biliary Tract Impairment)

Class 1—Impairment of the Whole Person, 1—5%

There is an occasional episode of biliary tract dysfunction.

Class 2—Impairment of the Whole Person, 6—20%

There is recurrent biliary tract impairment irrespective of treatment.

Class 3—Impairment of the Whole Person, 21—45%

There is irreparable obstruction of the bile tract with recurrent cholangitis.

Class 4—Impairment of the Whole Person, 46—75%

There is persistent jaundice and progressive liver disease due to obstruction of the common bile duct.

Classes of Hernial Impairment

Class 1—Impairment of the Whole Person, 1—5%

Palpable defect in supporting structures of abdominal wall;

and

Slight protrusion at site of defect with increased abdominal pressure; readily reducible;

or

Occasional mild discomfort at site of defect but not precluding normal activity.

Class 2—Impairment of the Whole Person, 6—15%

Palpable defect in supporting structures of abdominal wall;

and

Frequent or persistent protrusion at site of defect with increased abdominal pressure; still manually reducible;

or

Frequent discomfort precluding heavy lifting, but not hampering normal activity.

Class 3—Impairment of the Whole Person, 16—30%

Palpable defect in supporting structures of abdominal wall;

and

Persistent, irreducible or irreparable protrusion at site of defect;

and

Limitation in normal activity.

Use the Combined Values Chart for determining the total whole person impairment if more than one category of impairment is used.

UPPER URINARY TRACT

Class 1—Impairment of the Whole Person, 1—14%

Diminution of upper-urinary-tract function is present as evidenced by creatinine clearance of 75 to 90 liters/24 hr (52 to 62.5 ml/min), or PSP excretion of 15% to 20% in 15 minutes.

or

Intermittent symptoms and signs of upper-urinary-tract dysfunction are present that do not require continuous treatment or surveillance.

Class 2—Impairment of the Whole Person, 15—34%

Diminution of upper-urinary-tract function is present as evidenced by creatinine clearance of 60 to 75 liters/24 hr. (42 to 52 ml/min.), or PSP excretion of 10% to 15% in 15 minutes.

or

Although creatinine clearance is greater than 75 liters/24 hr (52 ml/min.), or PSP excretion is more than 15% in 15 minutes, symptoms and signs of upper-urinary-tract disease or dysfunction necessitate continuous surveillance and frequent treatment.

Class 3—Impairment of the Whole Person, 35—64%

Diminution of upper-urinary-tract function is present as evidenced by creatinine clearance of 40 to 60 liters/24 hr. (28 to 42 ml/min.), or PSP excretion of 5% to 10% in 15 minutes.

or

Although creatinine clearance is 60 to 75 liters/24 hr (42 to 52 ml/min.), or PSP excretion is 10% to 15% in 15 minutes, symptoms and signs of upper-urinary-tract-disease or dysfunction are incompletely controlled by surgical or continuous medical treatment.

Class 4—Impairment of the Whole Person, 65—90%

Diminution of upper-urinary tract function is present as evidenced by creatinine clearance below 40 liters/24 hr (28 ml/min.), or PSP excretion below 5% in 15 minutes.

or

Although creatinine clearance is 40 to 60 liters/24 hr (28 to 42 ml/min.), or PSP excretion is 5% to 10% in 15 minutes, symptoms and signs of upper-urinary-tract disease or dysfunction persists despite surgical or continuous medical treatment.

NOTE: The individual with a solitary kidney, regardless of cause, should be rated as having 10% impairment of the whole person. This value is to be combined with any other permanent impairment (including any impairment in the remaining kidney) pertinent to the case under consideration. The normal ranges of creatinine clearance are: Males: 130 to 200 liters/24 hr (90 to 139 ml/min.), Females: 115 to 180 liters/24 hr (80 to 125 ml/min.). The normal PSP excretion is 25% or more in urine in 15 minutes.

URINARY DIVERSION

Permanent, surgically created forms of urinary diversion usually are provided to compensate for anatomic loss and to allow for egress of urine. They are evaluated as a part of, and in conjunction with, the assessment of the involved portion of the urinary tract.

Irrespective of how well these diversions function in the preservation of renal integrity and the disposition of urine, the following values for the diversions should be combined with those determined under the criteria previously given for the portion of the urinary tract involved.

URINARY BLADDER

When evaluating permanent impairment of the bladder, the status of the upper urinary tract must also be considered. The appropriate impairment values for both should be combined using the Combined Values Charts in order to determine the extent of impairment of the whole person.

Class 1—Impairment of the Whole Person, 1—10%

A person belongs in Class 1 when the patient has symptoms and signs of bladder disorder requiring intermittent treatment with normal function between episodes of malfunction.

Class 2—Impairment of the Whole Person, 11—20%

A person belongs in Class 2 when (a) there are symptoms and/or signs of bladder disorder requiring continuous treatment, or (b) there is good bladder reflex activity, but no voluntary control.

Class 3—Impairment of the Whole Person, 21 —30%

A patient belongs in Class 3 when the bladder has poor reflex activity, that is, there is intermittent dribbling, and no voluntary control.

Class 4—Impairment of the Whole Person, 31—40%

A patient belongs in Class 4 when there is no reflex or voluntary control of the bladder, that is, there is continuous dribbling.

URETHRA

When evaluating permanent impairment of the urethra, one must also consider the status of the upper urinary tract and bladder. The values for all parts of the urinary system should be combined using the Combined Values Charts to determine the extent of impairment of the whole person.

Class 1—Impairment of the Whole Person, 1—9%

A patient belongs in Class 1 when symptoms and signs of urethral disorder are present that require intermittent therapy for control.

Class 2—Impairment of the Whole Person, 10—20%

A person belongs in Class 2 when there are symptoms and signs of a urethral disorder that cannot be effectively controlled by treatment.

MALE REPRODUCTIVE ORGANS

The male reproductive organs include the penis, scrotum, testes, epididymides, spermatic cords, prostate, and seminal vesicles. The values of impairment of the male reproductive organs are given in the following sections for men 40-65 years of age. These values may be increased by 25% of a given value for those below the age of 40 years, and decreased by 25% for those over the age of 65 years. For instance, a 25% increase of a 20% impairment equals 25% impairment.

Penis

When evaluating impairment of the penis, it is necessary to consider impairment of both the sexual and the urinary functions. The degree of impairment of sexual function should be determined in accordance with the criteria that follow, and it should be combined with the appropriate value for an impairment of urinary function that is present to determine the impairment of the whole person.

Class 1—Impairment of the Whole Person, 1—9%

A patient belongs in Class 1 when sexual function is possible, but there are varying degrees of difficulty of erection, ejaculation, and/or sensation.

Class 2—Impairment of the Whole Person, 10—20%

A patient belongs in Class 2 when sexual function is possible and there is sufficient erection, BUT ejaculation and sensation are absent.

Class 3—Impairment of the Whole Person, 25%

A patient belongs in Class 3 when no sexual function is possible.

Scrotum

Class 1—Impairment of the Whole Person, 1—9%

A patient belongs in Class 1 when there are symptoms and signs of scrotal loss or disease and there is no evidence of testicular malfunction, although there may be testicular malposition.

Class 2—Impairment of the Whole Person, 10—15%

A patient belongs in Class 2 when (a) there are symptoms and signs of architectural alteration or disease such that the testes must be implanted in other than a scrotal position to preserve testicular function, and pain or discomfort is present with activity; OR (b) there is total loss of the scrotum.

Testes, Epididymides, and Spermatic Cords

Class 1—Impairment of the Whole Person, 1—9%

A patient belongs in Class 1 when (a) symptoms and signs of testicular, epididymal, and/or spermatic cord disease are present and there is anatomic alteration; and (b) continuous treatments not required; and (c) there is no abnormality of seminal or hormonal function; or (d) a solitary testis is present.

Class 2—Impairment of the Whole Person, 10—15%

A patient belongs in Class 2 when (a) symptoms and signs of testicular, epididymal and/or spermatic cord disease are present and there is anatomic alteration; and (b) frequent or continuous treatment is required; and (c) there are detectable seminal or hormonal abnormalities.

Class 3—Impairment of the Whole Person, 16—20%

A patient belongs in Class 3 when trauma or disease produces bilateral anatomical loss, or there is no detectable seminal or hormonal function of the testes, epididymides, or spermatic cords.

Prostate and Seminal Vesicles

Class 1—Impairment of the Whole Person:, 1—9%

A person belongs in Class 1 when (a) there are symptoms and signs of prostatic and/or seminal vesicular dysfunction or disease, and (b) anatomic alteration is present; and (c) continuous treatment is not required.

Class 2—Impairment of the Whole Person, 10-15%

A patient belongs in Class 2 when (a) frequent severe symptoms and signs of prostatic and/or seminal vesicular dysfunction or disease are present; and (b) anatomic alteration is present; and (c) continuous treatment is required.

Class 3—Impairment of the Whole Person, 16—20%

A patient belongs in Class 3 when there has been ablation of the prostate and/or seminal vesicles.

FEMALE REPRODUCTIVE ORGANS

Vulva-Vagina

Class 1—Impairment of the Whole Person, 1—14%

A patient belongs in Class 1 when (a) symptoms and signs of disease or deformity of the vulva and/or vagina are present that do not require continuous treatment; and (b) sexual intercourse is possible; and (c) the vagina is adequate for childbirth during the premenopausal years.

Class 2—Impairment of the Whole Person, 15—29%

A patent belongs. Class 2 when (a) symptoms and signs of disease or deformity of the vulva and/or vagina are present that require continuous treatment; and (b) sexual intercourse is possible with varying degrees of difficulty; and (c) during the premenopausal years, adequacy for vaginal delivery is limited.

Class 3—Impairment of the Whole Person, 30—35%

A patient belongs in Class 3 when (a) symptoms and signs of disease or deformity of the vulva and/or vagina are present that are not controlled by treatment; and (b) sexual intercourse is not possible; and during the premenopausal years, vaginal delivery is not possible.

Cervix-Uterus

Class 1—Impairment of the Whole Person, 1 – 14%

A patient belongs in Class 1 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are present that do not require continuous treatment; or (b) cervical stenosis, if present, requires no treatment; or (c) there is anatomic loss of the cervix and/or uterus in the postmenopausal years.

Class 2—Impairment of the Whole Person, 15 – 29%

A patient belongs in Class 2 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are present that require continuous treatment; or (b) cervical stenosis, if present, requires periodic treatment.

Class 3—Impairment of the Whole Person, 30 – 35%

A patient belongs in Class 3 when (a) symptoms and signs of disease or deformity of the cervix and/or uterus are present that are not controlled by treatment; or (b) cervical stenosis is complete; or (c) anatomic or complete functional loss of the cervix and/or uterus occurs in premenopausal years.

Fallopian Tubes-Ovaries

Class 1—Impairment of the Whole Person, 1 – 14%

A patient belongs in Class 1 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or ovaries are present that do not require continuous treatment; or (b) only one fallopian tube and/or ovary is functioning in the premenopausal years; or (c) there is bilateral loss of function of the fallopian tubes and/or ovaries in the postmenopausal years.

Class 2—Impairment of the Whole Person, 15 – 29%

A patient belongs in Class 2 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or ovaries are present that require continuous treatment, but tubal patency persists and ovulation is possible.

Class 3—Impairment of the Whole Person, 30 – 35%

A patient belongs in Class 3 when (a) symptoms and signs of disease or deformity of the fallopian tubes and/or ovaries are present and there is total loss of tubal patency or total failure to produce ova in the premenopausal years; or (b) bilateral loss of the fallopian tubes and/or ovaries occurs in premenopausal years.