--- title: "Part V, Subpart iii, Chapter 12, Section C Progressive Neurological Disorders" document: "M-21-1" section: "Part V, Subpart iii, Chapter 12, Section C" canonical: "https://veteranai.co/va-regulations/m21-1/v.iii.12.c-progressive-neurological-disorders" source: "https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000180833/M21-1-Part-V-Subpart-iii-Chapter-12-Section-C-Progressive-Neurological-Disorders" updated: "2026-09-07T14:37:18.919551Z" --- April 16, 2020 ### V.iii.12.C.1.a. Definition: MS ** _Multiple sclerosis _**(MS) is a slowly progressive central nervous system disease 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) 8018-754240% from 12-10-19| Multiple sclerosis with bladder dysfunction 852010% from 12-10-19| Weakness of right lower extremity secondary to multiple sclerosis 852010% from 12-10-19| Weakness of left lower extremity secondary to multiple sclerosis 7599-75220% 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. **Reference:** For more information on evaluating MS, see [_Suggested Diagnostic Codes for Parkinson's disease, Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS)_](). ### 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 * [38 CFR 3.307(a)]() * [38 CFR 3.309](), and * [M21-1, Part V, Subpart ii, 2.B](). ## 2. ALS This topic contains information about ALS, including * definition of ALS * establishing presumptive SC for ALS * assigning a 100-percent evaluation for all cases of ALS * rating guidelines for ALS * example of rating ALS with * no complication warranting 100 percent on its own, and * a single complication warranting 100 percent * ALS and ancillary benefits, and * authority to decide ALS claims. July 17, 2025 ### 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_** * 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 * liberalizing changes of law and Department of Veterans Affairs (VA) issuances, see [M21-1, Part V, Subpart ii, 4.A.6]() * authority to decide ALS claims, see M21-1, Part V, Subpart iii, 12.C.2.h, and * active-duty service for establishing entitlement to SC for ALS on a presumptive basis, see [_Hansen-Sorensen v. Wilkie_](), 909 F.3d 1379 (Fed. Cir. 2018). ### V.iii.12.C.2.c. Assigning a 100 Percent Evaluation for All Cases of 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 to be assigned for all cases of 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 determining effective dates and retroactive benefits._**Reference**_ : For more information on SMC and ancillary benefits based on ALS, see M21-1, Part V, Subpart iii, 12.C.2.g. ### V.iii.12.C.2.d. Rating 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 on rating ALS. | **If ...**| **Then ...** there is no ALS complication warranting a single 100-percent evaluation on its own| * assign a 100-percent evaluation under [38 CFR 4.124a, DC 8017]() * include all compensable complications in the description of the diagnosis * grant any SMC warranted based on the ALS complications and level of disability shown, and * grant entitlement, if not already established, to * Dependents’ Educational Assistance (DEA) * automobile allowance and adaptive equipment, and * specially adapted housing (SAH). _**Reference**_ : For more information on rating ALS with no complication warranting a 100-percent evaluation on its own, see M21-1, Part V, Subpart iii, 12.C.2.e. a single 100-percent evaluation is warranted for a complication of ALS| * assign a 100-percent evaluation for that complication, using a hyphenated DC (for example, _8017-5110, amyotrophic lateral sclerosis with loss of use of both feet_) * separately evaluate additional complications, using only the applicable DC for each additional complication and showing each as secondary to ALS * grant any SMC warranted based on the ALS complications and level of disability shown, and * grant entitlement, if not already established, to * DEA, * automobile allowance and adaptive equipment, and * SAH. _**Important**_ : 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._**Reference**_ : For more information on rating ALS with a single complication warranting a 100-percent evaluation, see M21-1, Part V, Subpart iii, 12.C.2.f. **References:** For more information on * evaluating ALS, see [_Suggested Diagnostic Codes for Parkinson's disease, Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS)_](), and * SMC and ancillary benefits warranted based on ALS, see M21-1, Part V, Subpart iii, 12.C.2.g. ### V.iii.12.C.2.e. Example: Rating ALS With No Complication Warranting 100 Percent on Its Own This exhibit contains an example of rating ALS with no complication warranting a 100-percent evaluation on its own._**Coded Conclusion**_ : SUBJECT TO COMPENSATION (1. SC)8017 AMYOTROPHIC LATERAL SCLEROSIS WITH LOSS OF USE OF THE LEFT FOOT AND PARTIAL NINTH CRANIAL NERVE PARALYSIS100 percent from 05/10/2025._COMBINED EVALUATION FOR COMPENSATION:_ 100 percent from 05/10/2025._SPECIAL MONTHLY COMPENSATION_ 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 one foot from 05/10/2025.The appropriate SMC coding is shown in the table below.| **EFFECTIVE DATE**| **BASIC**| **HOSPITAL**| **LOSS OF USE**| **ANAT. LOSS**| **OTHER LOSS** 05/10/2025| 01| 01| 13| 00| 0 _ANCILLARY DECISIONS_ Entitled to Automobile and Adaptive Equipment Entitled to Specially Adapted Housing Basic Eligibility under 38 USC Ch 35 from 05/10/2025 ### V.iii.12.C.2.f. Example: Rating ALS With a Single Complication Warranting 100 Percent This exhibit contains an example of rating ALS with a single complication warranting a 100-percent evaluation plus additional compensable complications.**Coded Conclusion:** SUBJECT TO COMPENSATION (1. SC)8017-5110 AMYOTROPHIC LATERAL SCLEROSIS WITH LOSS OF USE OF BOTH FEET100 percent from 10/28/2024.7542 VOIDING DYSFUNCTION ASSOCIATED WITH AMYOTROPHIC LATERAL SCLEROSIS WITH LOSS OF USE OF BOTH FEET40 percent from 10/28/2024.7203 ESOPHAGEAL STRICTURE ASSOCIATED WITH AMYOTROPHIC LATERAL SCLEROSIS WITH LOSS OF USE OF BOTH FEET30 percent from 10/28/2024.9434 MAJOR DEPRESSIVE DISORDER ASSOCIATED WITH AMYOTROPHIC LATERAL SCLEROSIS WITH LOSS OF USE OF BOTH FEET30 percent from 10/28/2024._COMBINED EVALUATION FOR COMPENSATION_ :100 percent from 10/28/2024._SPECIAL MONTHLY COMPENSATION_ L-1 Entitled to special monthly compensation under 38 U.S.C. 1114, subsection (l) and 38 CFR 3.350(b) on account of loss of use of both feet from 10/28/2024.P-1 Entitled to special monthly compensation under 38 U.S.C. 1114, subsection (p) and 38 CFR 3.350(f)(3) at the rate intermediate between subsection (l) and subsection (m) on account of entitlement to the rate equal to subsection (l) with additional disability(ies), voiding dysfunction, esophageal stricture, and major depressive disorder, independently ratable at 50 percent or more from 10/28/2024.The appropriate SMC coding is shown in the table below. | **EFFECTIVE DATE**| **BASIC**| **HOSPITAL**| **LOSS OF USE**| **ANAT. LOSS**| **OTHER LOSS** 10/28/2024| 18| 18| 24| 00| 0 ** _ _** _ANCILLARY DECISIONS_ Entitled to Automobile and Adaptive Equipment Entitled to Specially Adapted Housing Basic Eligibility under 38 USC Ch 35 from 10/28/2024 ### V.iii.12.C.2.g. 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 a single 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, totals 60 percent or higher. * Entitlement to SMC, such as SMC (k) for loss of use of a foot, may still be warranted when a single, total disability evaluation is assigned for ALS and all complications under [38 CFR 4.124a, DC 8017](). * Effective December 3, 2013, [38 CFR 3.809(d)]() provides that SC ALS is a qualifying condition for the purpose of entitlement to SAH. * 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 * SMC, see [M21-1, Part VIII, Subpart iv, 4.A]() * ancillary benefits, see [M21-1, Part I, Subpart ii, 2.4]() * automobile allowance and adaptive equipment, see [M21-1, Part XIII, Subpart i, 2.A]() * SAH, see [M21-1, Part XIII, Subpart i, 2.B](), and * addressing all complications and ancillary benefits within scope of the claim, see [M21-1, Part V, Subpart ii, 3.A](). ### V.iii.12.C.2.h. 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 This topic contains information on Parkinson’s disease, including * definition of * Parkinson’s disease, and * Parkinsonism * SC for Parkinson’s disease and Parkinsonism * evaluating Parkinson’s disease and Parkinsonism, and * SMC and Parkinson’s disease/Parkinsonism. 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 * presumptive SC, see [M21-1, Part V, Subpart ii, 2.B]() * conditions presumptively related to herbicide exposure in the RVN, see * [39 CFR 3.309(e)](), and * [M21-1, Part VIII, Subpart i]() * secondary SC of conditions related to TBI, see [M21-1, Part V, Subpart iii, 12.B]() * considering whether a medical diagnosis has probative value, see [M21-1, Part V, Subpart ii, 1.A]() * determining whether to require further development, see [M21-1, Part V, Subpart ii, 3.B.1.a](), and * determining whether examinations are insufficient for rating purposes and obtaining clarification, see [M21-1, Part IV, Subpart i, 3.C](). ### V.iii.12.C.3.d. Evaluating Parkinson’s Disease and Parkinsonism Evaluate * Parkinson's disease using the diagnostic criteria for paralysis agitans under [38 CFR. 4.124a, DC 8004](), and * Parkinsonism by analogy to paralysis agitans under [38 CFR. 4.124a, DC 8004](), using DC 8099-8004. Use the same rating guidance as for MS as provided in M21-1, Part V, Subpart iii, 12.C.1.b. **Reference:** For more information on evaluating Parkinson’s disease, see [_Suggested Diagnostic Codes for Parkinson's disease, Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS)_](). ### 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 * loss of use, see [M21-1, Part VIII, Subpart iv, 4.A.4](), and * the level of disability required for entitlement to A&A, see [M21-1, Part VIII, Subpart iv, 4.A.8.b]().