Part 12.2 is to be applied to assess loss of haemopoietic function. The haemopoietic system consists of all the tissues, such as bone marrow and lymph nodes, that produce blood cells.
PART 12.1: THE ENDOCRINE SYSTEM
Many endocrine conditions will affect various other body systems. Hence, loss of endocrine function is established by assessing the effect of the condition on those other body systems. In very severe cases, where many body systems are affected, Table 16.2 in Chapter 16 (Activities of Daily Living) is to be applied to rate the loss of function.
In many cases, an endocrine condition will be under therapeutic control as a result of the use of continuous replacement therapy or the like. In these cases, the effect on other body systems may be minimal and the veteran’s principal inconvenience is that of undergoing the continuous therapy. This is to be assessed by applying the Other Impairment tables.
Calculation of the impairment rating for loss of endocrine function
Follow the steps below to calculate the impairment rating due to accepted loss of endocrine function.
(Each step is elaborated in the following pages.)
STEP 1
Establish which body systems are affected by the accepted endocrine condition.
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STEP 2
Determine an impairment rating for functional impairment of the affected body systems.
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STEP 3
Determine an Other Impairment rating for the accepted endocrine condition.
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STEP 4
Compare the total functional impairment rating of the affected body systems with the rating obtained in Step 3. Take the higher rating.
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STEP 5
If recognisable episodes of increased impairment are superimposed on the underlying condition, also assess the endocrine condition under Chapter 15 (Intermittent Impairment).
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Step 1: Establish which body systems are affected by the accepted endocrine condition.
Many of the effects of loss of endocrine function are separate and recognisable diseases. For example, diabetes mellitus may lead to ischaemic heart disease. Such diseases, though quite possibly a consequence of the loss of endocrine function, are to be separately assessed under this Guide and are not to be taken into account in the calculation of the impairment rating for loss of endocrine function.
Step 2: Determine an impairment rating for functional impairment of the affected body systems.
Use the appropriate Functional Loss tables from other chapters in this Guide to determine the impairment rating.
Step 3: Determine an Other Impairment rating for the accepted endocrine condition.
There are two Other Impairment tables for loss of endocrine function. Table 12.1.1 is to be applied if assessing diabetes mellitus, while Table 12.1.2 is be applied if assessing any other endocrine condition. Both tables provide an impairment rating based on the type of treatment required by the veteran.
Step 4: Compare the total functional impairment rating of the affected body systems with the rating obtained in Step 3. Take the higher of these two ratings.
The rating obtained in Step 4 is to be included in the final combining of all ratings.
Step 5: If recognisable episodes of increased impairment are superimposed on the underlying condition, also assess the endocrine condition under Chapter 15 (Intermittent Impairment).
If recognisable episodes of increased impairment are superimposed on the underlying condition (for example, insulin‑dependent diabetes with superimposed hypoglycaemic episodes), the endocrine condition is to be assessed under Chapter 15 (Intermittent Impairment). The rating from Chapter 15 and the rating obtained in Step 4 are to be included in the final combining of all ratings.
However, a rating from Chapter 15 is not to be combined with a rating from any other system‑specific table for the same condition.
Other Impairment Table 12.1.1 Combined male and female symbol
DIABETES MELLITUS
Impairment Ratings Criteria
NIL Glycosuria or hyperglycaemia controlled by weight loss.
TWO Gestational diabetes mellitus.
FIVE Diabetes mellitus necessitating dietary control.
Diabetes mellitus controlled by use of oral hyperglycaemics.
TEN Diabetes mellitus controlled with insulin.
TWENTY Diabetes mellitus uncontrolled.
A rating from this table is to be selected when the endocrine disorder is not associated with loss of function. If an assessable loss of function occurs in another system the higher rating is to be chosen. The two are not to be combined.
No age adjustment permitted for this table
For the purposes of Table 12.1.1, “Diabetes mellitus uncontrolled” means blood sugar level consistently 15 mmol/L or more, despite treatment.
Other Impairment Table 12.1.2 Combined male and female symbol
ENDOCRINE DISORDERS (excluding Diabetes Mellitus)
Impairment Ratings Criteria
NIL An endocrine disorder controlled by regular oral medication taken less often than daily or by injections less often than once a month.
TWO An endocrine disorder requiring daily oral medication. An endocrine disorder requiring regular injections not more often than once a month.
FIVE An endocrine disorder requiring injections not more often than once a fortnight.
TEN An endocrine disorder requiring daily injections.
A rating from this table is to be selected when the endocrine disorder is not associated with loss of function. If an assessable loss of function occurs in another system the higher rating is to be chosen. The two are not to be combined.
No age adjustment permitted for this table
PART 12.2: THE HAEMOPOIETIC SYSTEM
Conditions of the haemopoietic system include anaemias, leukaemias and polycythaemia.
Haemopoietic conditions usually affect various other body systems, therefore loss of function for the condition is to be established by assessing the effect of the condition on those body systems. Some haemopoeitic conditions are also malignant conditions and may be assessed by applying Chapter 14 (Malignant Conditions). For very severe haemopoietic conditions, where many body systems are affected, Tables 16.1 and 16.2 in Chapter 16 (Activities of Daily Living) are also to be applied to rate the loss of function.
Many anaemias will respond adequately to replacement or supplemental therapy. For example, the hypochromic anaemia of iron deficiency will usually respond to dietary iron supplementation and pernicious anaemia will usually respond to parenteral Vitamin B12.
Calculation of the impairment rating for loss of haemopoietic function
Follow the steps below to calculate the impairment rating due to accepted loss of haemopoietic function:
(Each step is elaborated on the following page.)
STEP 1
Establish which body systems are affected by the accepted haemopoietic condition.
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STEP 2
Determine the impairment rating for functional impairment of the affected body systems.
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STEP 3
Determine the impairment rating for the treatment requirements of the haemopoietic condition by applying Table 12.2.1.
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Step 1: Establish which body systems are affected by the accepted haemopoietic condition.
Haemopoietic conditions may affect the function of other body systems. For example, refractory anaemia may result in reduced effort tolerance.
Step 2: Determine the functional impairment of all body systems affected by the haemopoietic condition.
Apply the appropriate functional impairment table elsewhere in this Guide to assess the functional impairment arising from the haemopoietic condition. For example, in the case of refractory anaemia causing reduced effort tolerance, the reduced effort tolerance is to be assessed by use of the Effort Tolerance protocol in Chapter 1.
If non‑accepted conditions have contributed to the impairment rating for any of the affected body systems, Chapter 19 (Partially Contributing Impairment) is to be applied.
The various functional impairment ratings are not combined at this stage but are to be included in the final combining of all impairment ratings.
Step 3: Determine the impairment rating for the treatment requirements of the accepted haemopoietic condition using Table 12.2.1.
The ratings obtained in Steps 2 and 3 are not to be combined at this stage but both are to be included in the final combining of all impairment ratings.
Other Impairment Table 12.2.1 Combined male and female symbol
THE HAEMOPOIETIC SYSTEM: TREATMENT REQUIREMENTS*
Impairment Ratings Criteria
NIL Symptoms in remission and no active therapy indicated.
TWO Transfusion requirements: 2–3 units per 12–16 weeks.
FIVE Intermittent combination cytotoxic therapy — one course every 3–4 weeks. Phlebotomy once every 4 weeks. Transfusion requirements: 2–3 units per 6 weeks.
TEN Phlebotomy more than once every 4 weeks. Transfusion requirements: 2–3 units per 4 weeks.
TWENTY Transfusion requirements: 2–3 units per 2 weeks.
(*Additional to relevant body system assessment.)
No age adjustment permitted for this table
Part B: Non‑System Specific Assessment
CHAPTER 13
NEGLIGIBLE IMPAIRMENT
INTRODUCTION
As every accepted condition is to be assessed, Table 13.1 provides a convenient method of rating any accepted condition which causes negligible impairment. Table 13.1 is to be applied only to conditions that cannot be conveniently classified under other chapters of this Guide and that would not attract a higher rating if they were classified under such chapters.
Determine the impairment rating for an accepted condition that causes negligible impairment
Follow the step below to calculate the negligible impairment due to an accepted condition.
STEP 1
Determine the rating for negligible impairment from Table 13.1.
Functional Loss Table 13.1 Combined male and female symbol
NEGLIGIBLE IMPAIRMENT
Impairment Rating Criteria
NIL An infectious disease from which the veteran has recovered with negligible after effects. An injury from which the veteran has recovered with negligible after effects. A condition causing no current impairment. condition from which the veteran has recovered with negligible after effects.
No age adjustment permitted for this table
CHAPTER 14
MALIGNANT CONDITIONS
INTRODUCTION
Malignant conditions may affect one or more body systems.
Hence, any malignant condition can potentially be assessed by the following methods:
by applying the system‑specific tables contained in Chapters 1 to 12. A number of those tables may have to be consulted if the malignant condition causes multiple losses of function;
by applying Chapter 14 which relates specifically to malignancies and which contains both a Functional Loss table and an Other Impairment table. These tables are designed to rate the malignant condition as a whole. The first table relates to loss of function in a general sense. The second table relates to reduced life expectancy which is regarded as an Other Impairment.
If the impairment rating from Chapter 14 is 70 points on the basis of either the malignant disorders functional table (Table 14.1) or the malignant disorders Other Impairment table (Table 14.2), there is no need to follow the steps set out in the following pages. If the rating from Chapter 14 is below 70 points, the steps are to be followed.
Determine the impairment rating for an accepted malignant condition
Follow the steps below to calculate the impairment due to an accepted malignant condition.
(Each of these steps is elaborated in the following pages.)
STEP 1
Establish which body systems are affected by the malignant condition.
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STEP 2
Determine the functional impairment ratings for the affected body systems.
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STEP 3
Determine the total combined impairment rating for the various body system impairments attributable to the malignant condition.
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STEP 4
Determine the impairment rating based on Table 14.1 (Malignant Disorders).
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STEP 5
Determine the impairment rating based on Table 14.2 (Life Expectancy).
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STEP 6
Compare the ratings obtained in Steps 4 and 5. Take the higher rating.
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STEP 7
Compare the ratings obtained in Steps 3 and 6. Take the higher rating.
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STEP 8
If the rating obtained in Step 3 is higher than that obtained in Step 6, separate the components of the rating obtained in Step 3 so that each can be included in the final combining of all ratings.
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Step 1: Establish which body systems are affected by the malignant condition.
Before a malignant condition is assessed, information regarding the extent of the condition must be available. Such information includes the site of the primary, the sites of any secondaries, the effects of any surgery and the effects of any radiotherapy or chemotherapy.
From that information the affected body systems can be established and the applicable chapters of this Guide applied.
For example, in the case of an accepted carcinoma of the rectum, there may be surgical resection of the rectum with a colostomy, secondary spread of the cancer to the lungs and spine, and radiotherapy with some resultant digestive disturbances. In such a case, Chapters 1, 3, and 6 of this Guide will have to be applied in Step 1 to arrive at an appropriate functional impairment rating.
Step 2: Determine the functional impairment ratings for the affected body systems.
Depending on the body systems that are affected by the malignant condition and its treatment, each of the relevant chapters of the Guide is to be used and appropriate ratings obtained.
If other accepted or non‑accepted conditions also affect any of the same body systems, Chapter 19 (Partially Contributing Impairment) or Chapter 20 (Apportionment) may have to be applied depending upon the circumstances.
Step 3: Determine the total combined impairment rating for the various body system impairments attributable to the malignant condition.
The total combined impairment rating for the various body system impairments associated with the malignant condition is determined by combining the attributable impairment ratings by applying Chapter 18 (Combined Values Chart).
Unless the malignant condition is the only accepted condition, this combined rating is to be regarded as an intermediate rating only.
Step 4: Determine the impairment rating based on Table 14.1 (Malignant Disorders).
Apply Table 14.1 and find the relevant impairment rating for the entire set of effects which have arisen from the malignant disorder treatment, including surgical resection, chemotherapy and radiotherapy.
For the purposes of Table 14.1, “symptoms” encompasses the symptoms of both the malignant condition itself and the symptoms of the effects of its treatment.
If non‑accepted conditions or accepted but non‑malignant conditions have contributed to the impairment rating obtained from Table 14.1, Chapter 19 (Apportionment) or Chapter 20 (Partially Contributing Impairment) are to be applied depending on the circumstances of the case.
Step 5: Determine the impairment rating based on life expectancy.
If an impairment rating has not been determined on any previous occasion by applying Table 14.2 (Life Expectancy) or its predecessor in an earlier edition of this Guide, a rating is to be obtained from Table 14.2. If a rating has been obtained from Table 14.2 or its predecessor in an earlier edition of this Guide, on a previous occasion, that same rating is to be applied again in all further assessments of the condition.
Whenever possible, the rating from Table 14.2 is to be based on an estimate from an oncologist or other treating specialist of the veteran’s survival. If such information is unavailable, data from standard reference texts is to be applied to provide an estimate. Such an estimate is to be based on malignancies of the same type and degree of spread as that affecting the veteran.
Estimated life expectancy is projected from the time of diagnosis, or from any subsequent major staging procedure or operation. Thus, once a rating from Table 14.2 has been made it is not to be changed, unless subsequent findings indicate that the earlier prognosis was based on incorrect clinical information.
If the assessment is made posthumously, the rating from Table 14.2 is not to be modified to reflect the actual duration for which the veteran survived after diagnosis. The table is only to be used for predicted probability of survival.
Ratings from Table 14.2 are not to be updated to account for the natural progression of the disease. However, it is expected that ratings from Table 14.2 will come to be exceeded by ratings from Table 14.1 during this time.
Ratings from Table 14.2 are not to be reduced because of favourable response to treatment, or because of better than expected survival. However, if the condition is being rated for the first time more than five years after diagnosis, and the disorder is in remission or appears to be cured, the impairment rating from this table is not to exceed ten.
If the veteran has more than one malignant condition accepted, Table 14.2 is to be applied to each condition. Table 14.2 is not to be applied to a recurrence of an old (already diagnosed) condition.