Part V, Subpart iii, Chapter 12, Section CProgressive Neurological Disorders

Revised 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)

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.

2ALS

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.

Revised 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.

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.

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.

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.

3Parkinson'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.

Revised 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.