2.48. Traumatic Brain Injury (TBI)
VA uses DC 8045, "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified," to rate the residuals of traumatic brain injury (TBI). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day.
VA states that the evaluation table contains "10 important facets of TBI" related to cognitive impairment and subjective symptoms. Each facet is rated on five criteria ranging from 0 to 3 and "total," although not every criterion has every level of severity. If a facet is rated "total," a rating of 100% is assigned. If no facet is rated total, the overall percentage is based on the level of the highest facet with 0 = 0%, 1 = 10%, 2 = 40%, and 3 = 70% ratings. See 38 C.F.R. § 4.124a.
Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of TBI, whether or not part of cognitive impairment, are evaluated under the subjective symptoms in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, should be separately evaluated, even if that diagnosis is based on subjective symptoms.
Emotional and behavioral dysfunction is evaluated under section 4.130 (Schedule of ratings – Mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, emotional and behavioral symptoms are evaluated under the criteria in the table "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction is evaluated based on the following list, under the appropriate diagnostic code:
- motor and sensory dysfunction, including pain, of the extremities and face;
- visual impairment;
- hearing loss and tinnitus;
- loss of sense of smell and taste;
- seizures; gait, coordination, and balance problems;
- speech and other communication difficulties, including aphasia and related disorders, and dysarthria;
- neurogenic bladder;
- neurogenic bowel; cranial nerve dysfunctions;
- autonomic nerve dysfunctions; and
- endocrine dysfunctions.
This list of physical dysfunctions does not encompass all possible residuals of TBI. Residuals not listed here that are reported on an examination, should be evaluated separately under the most appropriate diagnostic code. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table should be considered for the evaluation for a single condition for purposes of combining with other disability evaluations.
Special monthly compensation may be appropriate for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc.
There may be an overlap of manifestations of conditions evaluated under the table with manifestations of a co-morbid mental, neurologic, or other physical disorder that can be separately evaluated under another DC. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions should be assigned. However, if the manifestations are clearly separable, a separate evaluation for each condition should be assigned.
When considering the proper rating the "instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Similarly, the terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning.
A veteran whose residuals of TBI are rated under a version of section 4.124a, DC 8045, in effect before October 23, 2008 may request review under DC 8045, irrespective of whether his or her disability has worsened since the last review. VA should review the veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under the revised DC 8045. A request for review should be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case can the award be effective before October 23, 2008.
On January 16, 2014, new regulations went into effect regarding disabilities that VA will consider to be secondary to a service-connected TBI. The disabilities for which VA will assume secondary service connection, including the circumstances necessary for such a presumption, are listed below. The determination of the severity of a TBI will be based on the TBI symptoms at the time of injury or shortly thereafter.
- Parkinsonism, including Parkinson's disease following moderate or severe TBI;
- Unprovoked seizures following moderate or severe TBI;
- Dementias including presenile dementia of the Alzheimer type, frontotemporal dementia, and dementia with Lewy bodies, if manifest within 15 years following moderate or severe TBI;
- Depression if manifest within 3 years of moderate or severe TBI; or within 12 months of mild TBI; or
- Diseases of hormone deficiency that result from hypothalamo-pituitary changes if manifest within 12 months of moderate or severe TBI.