--- title: "Part V, Subpart iii, Chapter 6" document: "M-21-1" section: "Part V, Subpart iii, Chapter 6" canonical: "https://veteranai.co/va-regulations/m21-1/v.iii.6" source: "https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000014523/M21-1-Part-V-Subpart-iii-Chapter-6-Digestive-Disabilities" updated: "2026-09-07T14:37:17.135238Z" --- May 20, 2024 ### V.iii.6.1.a. Regulatory Framework for Assigning Evaluations for Digestive Disabilities Disabilities of the digestive system are rated using * [38 CFR 4.112]() (weight loss and nutrition) * [38 CFR 4.113]() (coexisting abdominal conditions), and * [38 CFR 4.114]() (the schedule of ratings for the digestive system). [38 CFR 4.112]() defines terms used in diagnostic criteria in [38 CFR 4.114]() that involve weight and nutrition. [38 CFR 4.113]() provides a general warning that certain coexisting digestive conditions (those listed in the prefatory instruction in [38 CFR 4.114]()) cannot be separately evaluated without pyramiding. [38 CFR 4.114]() contains diagnostic codes (DCs) and associated criteria for disabilities of the digestive system. It also contains a general principle that certain listed DCs cannot be separately evaluated and combined. ### V.iii.6.1.b. Prohibition of Separate Evaluations for Certain Coexisting Digestive Disabilities [38 CFR 4.114]() prohibits assigning separate evaluations for certain coexisting digestive disabilities. The purpose of the prohibition, as is further explained in [38 CFR 4.113]() and [38 CFR 4.14](), is so that digestive disabilities, particularly within the abdomen, with closely related overlapping manifestations will not be combined under [38 CFR 4.25](), resulting in extra compensation for the same disability or facet of disability.Assignment of separate evaluations for any combination of the following DCs is prohibited: * 7301 through 7329 * 7331 * 7342 * 7345 through 7350 * 7352, and * 7355 through 7357. **Exceptions:** Effective May 19, 2024, [38 CFR 4.114]() does not categorically prohibit evaluating hiatal hernia separately from another condition in the above list, as long as the specific evaluations do not pyramid under [38 CFR 4.14](). This is because as of that date, hiatal hernia ([38 CFR 4.114, DC 7346]()) is evaluated using the diagnostic criteria for esophageal stricture ([38 CFR 4.114, DC 7203]()), which is not included in the listed DCs. Additionally, some DCs provide instructions to rate residuals _not addressed in the diagnostic criteria_ under another DC. [38 CFR 4.114, DC 7319]() (irritable bowel syndrome (IBS)) contains a note that says, “Evaluate other symptoms of a functional digestive disorder, not encompassed by this diagnostic code, under the appropriate diagnostic code, to include gastrointestinal dysmotility syndrome (DC 7356), following the general principles of § 4.14 and this section.” When the primary DC for the diagnosis, and a DC for rating other residuals not encompassed in the primary DC are both listed in [38 CFR 4.114](), the evaluations _can_ be combined on a case-by-case basis as long as the symptoms used to provide each evaluation do not pyramid under [38 CFR 4.14](). **Important:** * Where disabilities that fall within the range of DCs above cannot be separately evaluated and included in a combined evaluation, a single evaluation will be assigned as provided in M21-1, Part V, Subpart iii, 6.1.c. As explained in that block, elevation of the evaluation may be appropriate. * When separately evaluating and combining DCs is prohibited under [38 CFR 4.114](), the _Codesheet_ must still reflect each service-connected (SC) disability. **Notes:** * Separately evaluating and combining 7200-series DCs (such as Barrett’s esophagus) with a 7300-series DC (such as IBS or Crohn’s disease) is not categorically prohibited by [38 CFR 4.114](). * Similarly, separately evaluating and combining multiple 7200-series DCs is not categorically prohibited. * Whenever considering DCs that are not included in the [38 CFR 4.114]() list above, always carefully consider whether specific diagnostic criteria will compensate the same facet of disability and therefore violate [38 CFR 4.14](). ### V.iii.6.1.c. Evaluating Coexisting Digestive Disabilities That Cannot Be Separately Evaluated Under [38 CFR 4.113]() and [38 CFR 4.114]() when there are coexisting digestive disabilities for which multiple evaluations cannot be assigned * a single rating will be assigned under the DC which reflects the predominant disability, and * that evaluation will be elevated to the next higher evaluation when the severity of the overall disability warrants it. The Veterans Benefits Management System – Rating (VBMS-R) Evaluation Builder is programmed to appropriately apply the provisions of [38 CFR 4.114]() **_but_** it is critical that * the user input the symptoms that support the elevation, and * the symptoms coincide with the criteria listed in the rating schedule. For instructions on proper application of the [38 CFR 4.114]() provision on assigning an evaluation in cases of multiple qualifying coexisting digestive disabilities see the table below.| **Step**| **Action** 1| Determine which of the coexisting digestive conditions is the predominant disability. **Important:** * To determine the predominant disability, determine the evaluation each condition would support on its own. The condition that has the highest disability evaluation is the predominant disability. * If the same evaluation would be assigned to each, go through the analysis in the steps, alternatively treating each condition as the predominant one to see if one alternative provides a more advantageous outcome to the Veteran. 2| Determine if there are symptoms of the non-predominant disability that do not overlap with those of the predominant disability. * If _yes_ , go to Step 3. * If _no_ , go to Step 4. 3| Reevaluate the predominant disability but this time also consider the non-overlapping symptoms of the non-predominant disability. **Important:** The non-overlapping symptoms must support a higher evaluation when applied to the DC criteria being utilized for the predominant disability. Determine if the resultant evaluation is higher than the evaluation for the symptoms of the predominant disability alone (as derived in Step 1). * If _yes_ , go to Step 5. * If _no_ , go to Step 4. 4| * Rate the coexistent disabilities together under the rating criteria for the predominant disability _without elevation_ to the next higher evaluation. * No further action necessary. 5| * Rate the coexistent disabilities together under the rating criteria for the predominant disability and elevate to the next higher evaluation. * No further action necessary. **Important:** The “next higher level of evaluation” is the lowest evaluation specified in the DC for the predominant disability _that provides greater compensation than the evaluation derived in Step 1_ (the evaluation that would be supported by only the symptoms of the predominant disability without the symptoms of the lesser disability). _**Do not simply add 10 percent**_. ### V.iii.6.1.d. Example: Evaluating Coexisting Digestive Disabilities ** _Situation_** : A Veteran has two coexisting digestive disabilities: * peptic ulcer disease meeting the criteria for a 20-percent evaluation under [38 CFR 4.114, DC 7304]() (two episodes of abdominal pain lasting for three consecutive days in duration in the past 12 months managed by daily prescribed medication), and * ulcerative colitis of the large bowel, meeting the criteria for a 30-percent evaluation under [38 CFR 4.114, DC 7323](), which is evaluated using the criteria for Crohn’s disease or undifferentiated inflammatory bowel disease in [38 CFR 3.114, DC 7326]() (mild disease managed with oral and topical agents other than immunosuppressants or other biologic agents, and characterized by recurrent abdominal pain with 3 or fewer daily episodes of diarrhea and minimal signs of toxicity including infrequent low grade fever). **Result:** _Separate_ evaluations for the peptic ulcer disease and ulcerative colitis are _not_ permitted under [38 CFR 4.114](). A single 30-percent evaluation under [38 CFR 4.114, DC 7323]() would be assigned. **Explanation:** Ulcerative colitis represents the predominant disability picture as it supports the higher evaluation on its own. There are no non-overlapping symptoms of peptic ulcer disease to establish any of the criteria supporting the next higher 60-percent evaluation for ulcerative colitis: moderate inflammatory bowel disease that is managed on an outpatient basis with immunosuppressants or other biologic agents; and is characterized by recurrent abdominal pain, four to five daily episodes of diarrhea; and intermittent signs of toxicity such as fever, tachycardia, or anemia. Therefore, the coexistent disabilities must be rated together under the rating criteria for the predominant disability _without elevation_ to the next higher 60-percent evaluation.**Situation:** A Veteran has two coexisting digestive conditions: * IBS, meeting the criteria for a 10-percent evaluation under [38 CFR 4.114, DC 7319]() (abdominal pain related to defecation at least once during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension), and * hiatal hernia, meeting the criteria for a 10-percent evaluation under [38 CFR 4.114, DC 7346](), which is rated as stricture of the esophagus under [38 CFR 4.114, DC 7203]() (documented history of esophageal stricture(s) that requires daily medications to control dysphagia otherwise asymptomatic). **Result:** Effective May 19, 2024, _separate_ evaluations for IBS and hiatal hernia are permitted under [38 CFR 4.114](). **Explanation:** Even though the DCs for hiatal hernia (7346) and IBS (7319) each fall within the range of DCs that the regulation says will not be separately evaluated and combined, they fall within the exception discussed in M21-1, Part V, Subpart iii, 6.1.b because effective May 19, 2024, [38 CFR 4.114, DC 7346]() is evaluated using the criteria in [38 CFR 4.114, DC 7203]() (stricture of the esophagus). The 10-percent criteria for the two DCs do not overlap. They do not compensate for the same disability or facet of disability, which is prohibited under [38 CFR 4.14](). Note that under historical criteria, these DCs could not be separately evaluated and combined without pyramiding. ### V.iii.6.1.e. Changes to the Rating Schedule for the Digestive System The schedule of ratings – digestive system, [38 CFR 4.114](), was amended effective May 19, 2024. The final rule added and deleted DCs, and extensively changed diagnostic criteria. The final rule also deleted regulations with obsolete or redundant guidance on ulcers ([38 CFR 4.110]()) and post-gastrectomy syndrome ([38 CFR 4.111]()). The purpose of the digestive system updates was to ensure that the rating schedule uses current medical terminology and to provide updated more objective evaluation criteria. The changes were** _not_** intended as a liberalization.When evaluating a claim involving evaluation of a digestive disability that was pending on May 19, 2024, apply the guidance in [M21-1, Part V, Subpart ii, 4.A.6.p]() on applicability of revised rating schedule criteria.**Important:** In some instances, a digestive disorder may have been evaluated under analogous DC – whether using formal conventions for rating by analogy or not. For example, prior to the current changes, gastroesophageal reflux disease (GERD) did not have its own DC. The recommended DC for GERD in the past was 7346 (hiatal hernia). It might appear on the _Codesheet_ as “7399-7346” or just “7346.” Now the DC is 7206. Where a condition was previously rated by analogy but now has a specific DC, update the DC, but when considering the appropriate current evaluation, apply [38 CFR 3.951(a)](). Do **_not_** reduce the evaluation solely based on the changed criteria. The evaluation can only be reduced when medical evidence establishes that the disability has actually improved. Note that in the case of hiatal hernia and GERD, although the latter condition has its own DC the criteria for evaluating the two conditions is the same. Hiatal hernia is rated as stricture of the esophagus ([38 CFR 4.114, DC 7203]()), which uses identical criteria to those in [38 CFR 4.114, DC 7206]().**Reference:** For more information on protection and rating schedule changes, and reviewing evaluations after a rating schedule change, see [M21-1, Part X, Subpart ii, 1.B.4](). ## 2. SC Considerations Involving Digestive Disabilities This topic contains information about SC considerations involving digestive disabilities, including * considering circumstances of service when determining SC for gastrointestinal disorders * testing not required for SC for GERD * establishing SC for inguinal hernia * SC and recurrence of hemorrhoids * example of analyzing recurrence of hemorrhoids * other causes of liver damage, and * fatty liver. October 17, 2024 ### V.iii.6.2.a. Considering Circumstances of Service When Determining SC for Gastrointestinal Disorders If the issue is service connection (SC) for dysentery or other gastrointestinal disease, assign great weight to any service under the following conditions since these conditions may have been the etiological or aggravating factor: * tropical service * imprisonment or internment under unsanitary conditions, or * food deprivation. **Reference:** For more information on establishing presumptive SC for dysentery and other tropical diseases, see [38 CFR 3.309(b)](). ### V.iii.6.2.b. Testing Not Required for SC for GERD A diagnosis of GERD for SC purposes does not require documentation by medical imaging. [38 CFR 4.114, DC 7206, Note (1)]() requires “findings” to be documented by one of three types of imaging: barium swallow, computed tomography (CT), or esophagogastroduodenoscopy. This refers to documentation of esophageal stricture for evaluation purposes. It does not define a sufficient diagnosis of GERD for SC purposes. **Note:** A 10-percent evaluation for GERD can also be assigned pursuant to [38 CFR 4.7]() without imaging to document esophageal stricture when the Veteran requires daily medications. ### V.iii.6.2.c. Establishing SC for Inguinal Hernia Do not assume the preexistence of a hernia. Determine preexistence on a factual basis. The following conditions are sufficient bases for SC: * in-service initial manifestation of hernial protrusion, and * recurrence during service, by aggravation, of a hernia previously surgically repaired. **Note:** Operation for repair of a preexisting inguinal hernia is not necessarily evidence of aggravation.**Reference:** For information on the presumption of soundness at entrance into service, see [38 CFR 3.304(b)](). ### V.iii.6.2.d. SC and Recurrence of Hemorrhoids Initial awards of SC for hemorrhoids are governed by customary rules for SC included in [38 CFR 3.303](). After SC is initially established, unless the award of SC for hemorrhoids was in error, consider recurrences after a period of absence of hemorrhoids post-service to be associated with the SC condition rather than a nonservice-connected superseding condition.**Reference:** For more information on reversing an erroneous decision, see * [38 CFR 3.105(a)](), and * [M21-1, Part X, Subpart ii, 5.A](). ### V.iii.6.2.e. Example: Analyzing Recurrence of Hemorrhoids ** _Situation_** : SC is established for hemorrhoids first diagnosed during service. A 0-percent evaluation was assigned under [38 CFR 4.114, DC 7336](). Two years after SC was granted for hemorrhoids, the Veteran filed a claim for increased evaluation. Examination showed no hemorrhoids. The diagnosis was “hemorrhoids, not shown.” The 0-percent evaluation was continued. Five years later the Veteran filed a claim for an increased evaluation for hemorrhoids. Records showed three instances of doctor visits in the last year for external hemorrhoids with thrombosis. The Veteran reported a history of “old” problems with hemorrhoids and recent symptoms including bright red blood noted with defecation and discomfort with protracted sitting in his current job. A Department of Veterans Affairs examination included a similar history and showed external hemorrhoids with thrombosis. The diagnosis was “external hemorrhoids.” Examination findings and findings in treatment records demonstrate the criteria for 10-percent evaluation in [38 CFR 4.114, DC 7336](). **Result:** Assign a 10-percent evaluation. The facts suggest that the SC hemorrhoids were non-disabling, or even absent, for an indeterminate period after SC was granted, and the Veteran’s current history in medical records and at the VA examination could suggest that the current hemorrhoids are due to a superseding post-service cause (protracted sitting at work). However, the evidence does not prove that current hemorrhoids are due to a superseding cause or that SC was in error. Pursuant to the principle in M21-1, Part V, Subpart iii, 6.2.d, after SC is initially established, consider hemorrhoids shown after a period of absence to be associated with the SC condition rather than due to a superseding post service cause unless the award of SC for hemorrhoids was clearly in error. Do not return the examination for comment on that question. ### V.iii.6.2.f. Other Causes of Liver Damage The table below describes recognized causes of liver damage and provides examples of each cause. | **Cause of Liver Damage**| **Example** Infection| Virus Systemic diseases| Lupus Drugs| * Isoniazid * Acetaminophen * Phenytoin Toxic substances| Alcohol ### V.iii.6.2.g. Fatty Liver Fatty liver, also called hepatic steatosis, is not a disability for which SC can be granted. By itself it is simply considered an abnormal laboratory finding. **Reference:** For more information on abnormal laboratory findings discovered in STRs without a claim, see [M21-1, Part V, Subpart ii, 3.C.1.d](). ## 3. Hepatitis This topic contains information about hepatitis, including * categories of hepatitis recognized for rating purposes * diagnostic testing required for hepatitis * interpreting lab reports for * hepatitis B (HBV), and * hepatitis C (HCV) after 1992 * risk factors for HBV and HCV * development for hepatitis risk factors * considering drug abuse in hepatitis claims * evaluating claims for increase for SC hepatitis awarded due to drug abuse * considering in-service hepatitis findings * requesting exams and/or opinions for HBV or HCV * reviewing hepatitis exams and opinions for sufficiency, and * assigning a 0-percent evaluation for HCV. April 21, 2025 ### V.iii.6.3.a. Categories of Hepatitis Recognized for Rating Purposes There are three main categories of viral hepatitis recognized for rating purposes. The table below describes each type of hepatitis and explains the transmission and prognosis for each.| **Type of Hepatitis**| **Transmission**| **Prognosis** hepatitis A virus (HAV), previously called infectious hepatitis| fecal-oral route| Acute—seldom severe and does not leave residuals.**Note:** In order to award SC, there must be evidence of chronic residuals related to the hepatitis A infection. hepatitis B virus (HBV), previously called serum hepatitis| * blood products * sexual contact * Acute in 90-95 percent of cases, but acute disease can be severe and result in death. * Chronic in 5-10 percent of cases. * Cirrhosis and liver cancer may develop. * A vaccine to prevent HBV infection is available. hepatitis C virus (HCV), previously called non-A non-B hepatitis| infected blood| * Clinically asymptomatic acute disease. * Chronic disease develops in 80 percent of cases following acute phase. * Diagnosis is generally made incidentally many years later. **Note:** Infectious hepatitis is common throughout the world and was especially prevalent during World War II following administration of the yellow fever vaccine in 1942 and in the Mediterranean Theater. **Reference:** For more information on risk factors for HBV and HCV, see M21-1, Part V, Subpart iii, 6.3.e. ### V.iii.6.3.b. Diagnostic Testing Required for Hepatitis SC for hepatitis requires blood serology testing to establish a diagnosis and identify the type of hepatitis present. Liver function tests (LFTs) are necessary to assess the severity of the disease.**Notes:** * The rating decision should always specify the type of hepatitis for which SC is awarded. * _Serological tests_ determine the presence of antigens and antibodies to the specific virus. The presence of antibodies to the specific virus indicates the infection is present. The table below describes types of serological testing required to confirm a diagnosis for each type of hepatitis.| **Type of Hepatitis**| **Serology or Other Testing Required**| **Additional Notes** HAV| anti-HAV (antibodies to hepatitis A virus)| * Anti-HAV are present in the blood one month after the acute illness and persist for life. * Serological blood testing showing the presence of anti-HAV indicates a past acute infection. HBV| * anti-HBsAg (hepatitis B surface antigen) is present during the acute phase. * HBsAg that persists more than three to six months indicates probable chronic disease or carrier status. * A positive Australian antigen test is sufficient to confirm HBV. | HBV has two antigens, a surface antigen and a core antigen * HBsAg, and * HBcAg (hepatitis B core antigen). Consequently, two types of antibodies appear in the blood * anti-HBs (antibodies to the surface antigen), and * anti-HBc (antibodies to the core antigen). HCV| * EIA (enzyme immunoassay) or ELISA (enzyme linked immunosorbent assay, also called Western blot) is the first test. * If EIA or ELISA is positive, RIBA (recombinant immunoblot assay) is needed to confirm the diagnosis of chronic HCV. * In lieu of EIA/ELISA followed by RIBA, a positive test for HCV RNA (hepatitis C viral ribonucleic acid) is sufficient by itself to confirm a diagnosis of HCV. * HCV RNA results can be * qualitative (positive or negative), or * quantitative (number of copies per milliliter (ml)). | The presence of anti-HCV (including EIA or ELISA) is **_not_** sufficient for a diagnosis of chronic HCV because it can be present in other diseases. **Note:** Liver biopsy, ultrasound, and CT scan tests can detect damage to the liver but will not identify the type of infection. ### V.iii.6.3.c. Interpreting Lab Reports for HBV The table below provides an example of a laboratory interpretation of serology test results for HBV.| **_Test_**| ** _Results_**| ** _Interpretation_** _**Example 1**_ _HBsAg_| negative| susceptible to infection _anti-HBc_| negative| susceptible to infection (no HBV) anti-HBs| negative| no history of HBV ** _Example 2_** HBsAg| negative| immune anti-HBc| negative or positive| immune anti-HBs| positive| ** _Example 3_** HBsAg| positive| acute infection anti-HBc| positive| Immunoglobulin M (IgM) anti-HBc| positive| acute infection anti-HBs| negative| ** _Example 4_** HBsAg| positive| chronic infection anti-HBc| positive| IgM anti-HBc| negative| chronic infection anti-HBs| negative| ### V.iii.6.3.d. Interpreting Lab Reports for HCV After 1992 The table below provides an example of a laboratory interpretation of serology testing for HCV for testing performed after 1992.| **_Tests_**| ** _Results_**| ** _Interpretation_** anti-HCV| positive (probable chronic hepatitis)| need to verify diagnosis EIA| positive| supplemental test required RIBA| positive| diagnostic HCVRNA| follow-up of chronic HCV| not needed for rating ### V.iii.6.3.e. Risk Factors for HBV and HCV Risk factors for the development of HBV and HCV are similar. The table below describes the medically recognized risk factors for HBV and HCV infection, provides transmission information concerning those risk factors, and includes tips for confirming the risk factors.**Note:** Resolve reasonable doubt under [38 CFR 3.102]() in favor of the Veteran when the evidence favoring risk factor(s) in service is equal to the evidence favoring risk factor(s) before or after service.| **Risk Factor**| **Transmission Information**| **Rating Tips** * transfusion of blood or blood product * before 1992 for HCV, or * before 1975 for HBV * organ transplant before 1992, or * hemodialysis * Blood donor screening for HCV was not available until 1989 when HCV was identified. * In 1992, more effective screening of blood became possible for HCV. * If blood transfusion is a claimed risk factor, obtain the relevant hospital records from service, if possible. * Look for evidence of blood transfusions in surgical reports, especially the * anesthesia sheet * surgical record * operative clinical records, or * post-operative clinical notes. * tattoos * body piercing, and * acupuncture with non-sterile needles | transmitted through the use of unsterilized equipment| Review for indications of tattoos or piercings on induction and separation exams to help determine whether tattooing or piercing took place in service. intravenous drug use| transmitted through the use of shared instruments| Records of drug treatment may reflect the type of drug abuse. high-risk sexual activity| Transmission risk is relatively low but increases with multiple sexual partners.| Periodic health assessments or records of treatment for sexually transmitted diseases may document a history of high-risk sexual activity or multiple sexual partners. intranasal cocaine use| transmitted through the use of shared instruments| Records of drug treatment may reflect the type of drug abuse. accidental exposure to blood by percutaneous exposure or on mucous membranes| common for the following: * health care workers * combat medics, and * corpsmen | Consider service department or other records reflecting occupational history. sharing of * toothbrushes, or * shaving razors | transmitted through direct percutaneous exposure to blood| This type of in-service exposure will not generally be documented in service records. Consider buddy statements in the context of the entire evidence picture pertaining to risk factors. immunization with a jet air gun injector| * _one_ documented case of HBV transmission * Despite the lack of any scientific evidence to document transmission of HCV with air gun injectors, it is biologically possible. | A medical report linking hepatitis to air gun injectors must include a full discussion of all potential modes of transmission and a rationale as to why the examiner believes the air gun injector was the source for the hepatitis infection. _**Reference**_ : For more information on development for and the concession of in-service risk factors associated with HCV, see [_Andrews v. McDonough_](), 34 Vet.App. 151 (2021). ### V.iii.6.3.f. Development for Hepatitis Risk Factors As [_VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits_](), does not inform the claimant to submit evidence of hepatitis risk factors, development for risk factors is required in every hepatitis claim, even when hepatitis is diagnosed in service. Development is necessary to determine if pre- and post-service risk factors are present as well as to ensure that the risk factor is not substance abuse either before or during service.Regardless of what claim form the Veteran submits, development for risk factors is required if the complete risk factor history has not already been provided. If risk factor history is not of record send a risk factor development letter to the Veteran._**References**_ : For more information on * SC for hepatitis associated with drug use, see M21-1, Part V, Subpart iii, 6.3.g, and * examinations and medical opinions in hepatitis claims, see M21-1, Part V, Subpart iii, 6.3.j. ### V.iii.6.3.g. Considering Drug Abuse in Hepatitis Claims If one of the risk factors for hepatitis is intravenous or intramuscular drug use, or intranasal cocaine use, do **_not_** automatically assume the substance abuse is the cause of hepatitis and deny the claim on that basis. Follow the steps in the table below when considering a claim for SC for hepatitis in which injection drug or intranasal cocaine use is a confirmed in-service risk factor. | **Step**| **Action** 1| Review for all risk factors of hepatitis in addition to the drug use. 2| If injection drug or intranasal cocaine use is the only confirmed in-service risk factor present, then deny SC. If other in-service risk factors are found in addition to injection drug or intranasal cocaine use, go to Step 3. 3| Request a medical opinion to determine which confirmed in-service risk factor is at least as likely as not the cause of the hepatitis infection. 4| Use the table below to determine how to proceed with the medical opinion.| **If the medical opinion …**| **Then …** states that drug use is the cause of the hepatitis infection| deny the claim for SC for hepatitis. gives greater or equal weight to another confirmed in-service risk factor| * resolve reasonable doubt in the Veteran’s favor, and * award SC. is unable to state which risk factor is more likely than not to be the cause of the hepatitis| * weigh all evidence, and * apply the reasonable doubt doctrine if the evidence is found to be in equipoise. **Reference:** For more information on examiner statements that an opinion would be speculative, see [M21-1, Part IV, Subpart i, 3.A.1.q](). **Reference:** For more information on considering claims for SC based on drug use, see * [38 CFR 3.301(c)(3)](), and * [M21-1, Part X, Subpart iv, 1.D.2](). ### V.iii.6.3.h.  Evaluating Claims for Increase for SC Hepatitis Awarded Due to Drug Abuse Follow the steps in the table below to determine the appropriate actions to take in a claim for increase when SC was previously awarded but the only apparent risk factor in service was drug abuse.| **Step**| **Action** **1**| Was SC for hepatitis due to drug abuse awarded by rating decision on or before October 31, 1990? * If _yes_ , then continue the finding of SC for hepatitis as the award of SC was proper based on regulations and procedures at that time. Go to Step 5. * If _no_ , then go to Step 2. 2| Does the evidence clearly show that the hepatitis is due to in-service drug abuse? * If _yes_ , go to Step 4. * If _no_ , go to Step 3. 3| If SC was awarded but there is no evidence clearly linking the hepatitis to drug abuse or if there were multiple risk factors in service, one of which was drug abuse, and no prior opinion was obtained, request a medical opinion to determine whether the hepatitis is due to the drug abuse.If the resulting opinion * clearly links hepatitis to drug abuse, go to Step 4. * cannot resolve whether hepatitis is due to drug abuse or another in-service risk factor, or the hepatitis is attributed to another non-drug abuse in-service risk factor, then * resolve reasonable doubt in favor of the Veteran and continue the finding of SC, and * award an increased evaluation for hepatitis if the medical evidence otherwise shows the increase is warranted. 4| If the evidence clearly shows that the hepatitis is due to in-service drug abuse and SC was awarded by rating decision after October 31, 1990, determine whether the award of SC is protected per [38 CFR 3.957](). * If SC. is protected, go to Step 5. * If SC is not protected, then propose to sever SC per [38 CFR 3.105(a)](). 5| If SC was properly established for hepatitis due to drug abuse by rating decision on or before October 31, 1990, and/or if the award of SC for hepatitis is protected, do not award an increased evaluation for hepatitis due to drug abuse. **Notes:** * The Omnibus Reconciliation Act of 1990 (_Public Law 101-508 Section 8052_) prohibited the grant of SC for disability or death resulting from alcohol or drug abuse for claims filed after October 31, 1990. * [VAOPGCPREC 2-1998]() found that an increased evaluation may not be awarded when SC was previously properly established as due to drug abuse by rating decision on or before October 31, 1990. ### V.iii.6.3.i. Considering In-Service Hepatitis Findings When a Veteran submits a claim for SC of hepatitis, assess the lay evidence, service treatment records (STRs), and current medical records to ascertain whether a current disability, an in-service event or injury, and an indication of an association are present as required in [38 CFR 3.159(c)(4)]() prior to requesting examination and/or medical opinion. Use the table below to determine the proper rating action for in-service findings related to hepatitis.| **If STRs show ...**| **Then ...** diagnosis of non-specific hepatitis and SC is claimed many years later| request an exam with serology testing and LFTs (if not already of record) and opinion to determine if a relationship exists between the episode of hepatitis in service and the current type of hepatitis unless there is sufficient evidence of a clearly-established diagnosis and continuous symptoms present to satisfy the nexus standard under [38 CFR 3.303(b)](). laboratory findings confirming HAV or HBV| * SC for HAV is not warranted as HAV is an acute condition. * Consider SC for HBV if a chronic disability is present and linked to the in-service finding and/or risk factors. * Consider SC for HCV if a medical opinion links the condition to the confirmed in-service findings and/or risk factors. However, do not automatically grant SC for HCV. The lab findings in service alone do not show HCV in service or allow a conclusion that HCV was incurred in service. Each type of hepatitis can be acquired at different times and through different means. a diagnosis of non-A, non-B hepatitis (old name for HCV) and the current medical evidence confirms a diagnosis of HCV| SC is likely warranted. * If medical evidence establishes the presence of continuous symptoms since service, then award SC. * If evidence of continuous symptoms since service is not present, request a nexus opinion. non-specific hepatitis and current evidence shows HCV **or** chronic HBV only| HCV or chronic HBV _may_ warrant SC based on reasonable doubt. Request a medical opinion and any necessary diagnostic testing to confirm the diagnosis.**Reference:** For more information on diagnostic testing required for hepatitis, see M21-1, Part V, Subpart iii, 6.3.b. non-specific hepatitis and current evidence shows HCV **or** chronic HBV as well as a history of HAV| a medical opinion is necessary to determine whether the current disability is a result of the non-specific hepatitis diagnosed in service. ### V.iii.6.3.j. Requesting Exams and/or Opinions for HBV or HCV Follow the steps in the table below when requesting an examination and/or opinion for HCV or chronic HBV.| **Step**| **Action** 1| Identify and request the examiner review of all relevant evidence in the claims folder. 2| List any risk factors identified by the Veteran. 3| Identify all risk factors confirmed by the evidence in the claims folder, whether claimed by the Veteran or not.**Important:** In addition to in-service risk factors, ensure that all documented pre- and post-service risk factors are noted in the exam request. 4| Request _Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire_. 5| Request a medical opinion about the relationship between the current HBV or HCV infection and confirmed or supported risk factor(s). 6| Notify the examiner that a positive nexus opinion, if warranted, should take only confirmed risk factors as shown by the objective evidence of record into consideration. **References:** For more information on * confirming risk factors, see M21-1, Part V, Subpart iii, 6.3.e, and * evaluating evidence, see [M21-1, Part V, Subpart ii, 1.A](). ### V.iii.6.3.k. Reviewing Hepatitis Exams and Opinions for Sufficiency Review the examination or opinion to ensure sufficiency and return insufficient examinations when warranted. Common reasons for insufficient examinations are * lack of proper confirmatory testing to support the diagnosis * failure to include complete clinical findings and symptoms in the report * failure to address all known risk factors in the opinion * opinions linking HCV or chronic HBV to a risk factor that is not confirmed in the evidence of record, and * opinions improperly linking HCV or chronic HBV to a risk factor that is not medically recognized as a source of infection. ### V.iii.6.3.l. Assigning a 0-Percent Evaluation for HCV To assign an evaluation for HCV ([38 CFR 4.114, DC 7354]()) use the criteria in [38 CFR 4.114, DC 7345]() (chronic liver disease without cirrhosis). A 0-percent evaluation should only be assigned for HCV when the condition is asymptomatic with a previous history of liver disease. Use the table below to determine when it is appropriate to assign a 0-percent evaluation for HCV.| **If medical evidence shows ...**| **Then a 0-percent disability evaluation is ...** even mild symptoms related to HCV infection| not appropriate because the Veteran is symptomatic. there is evidence of liver damage on LFTs, liver biopsy, or other testing| not appropriate because this means the infection is not _healed_. HCV has responded to therapy to the extent that RNA test results are negative, and the Veteran is now asymptomatic with no evidence of liver damage| appropriate. However, HCV remains dormant in the system and may flare up again later. **Reference:** For more information on evaluation of HCV, see [38 CFR 4.114, DC 7354]().