Part V, Subpart iii, Chapter 6

Revised 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.

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.

2SC 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.

Revised 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.

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.

3Hepatitis

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.

Revised 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.

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.

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.

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.

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.

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.

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 — Action1 — 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.

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.

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.

Reference: For more information on evaluation of HCV, see 38 CFR 4.114, DC 7354.