VA Disability Ratings for Lower Back Pain

CCK Law: Our Vital Role in Veterans Law

Veterans frequently experience low back pain following service. Low back conditions, depending on their severity, can greatly impact a veteran’s ability to perform activities of daily living or carry out work-related responsibilities. Therefore, if veterans can establish that their low back pain is a result of their military service, they may be eligible to receive VA disability benefits in the form of monthly compensation and VA healthcare.

How VA Rates Low Back Pain

VA disability compensation is usually based on the rating that VA assigns a veteran after determining that he or she has a service-connected condition.

In most cases, VA uses the General Rating Formula for Diseases and Injuries of the Spine under 38 CFR § 4.71a to evaluate back conditions, including low back pain. This general rating formula is based primarily on range of motion, or the measurement of the amount of movement around a specific joint or body part. The range of motion measurement typically encompasses the range of flexion (i.e., bending) and extension (i.e., straightening).

General Rating Formula for Spine Conditions

• 100% – unfavorable ankylosis of the entire spine
• 50% – unfavorable ankylosis of the entire thoracolumbar spine
• 40% – unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine
• 30% – forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine
• 20% – forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis
• 10% – forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of the height.

Alternative Rating Approach for Low Back Pain: Intervertebral Disc Syndrome

Importantly, if veterans do not meet the range of motion criteria outlined above, it is still possible to obtain a high rating for their low back pain if they have intervertebral disc syndrome (IVDS) as well. VA rates IVDS under Diagnostic Code 5243, which focuses on the number of incapacitating episodes veterans experience as a result of their low back pain. Here, VA defines an incapacitating episode as a period of acute signs and symptoms that requires bedrest as prescribed by a physician. IVDS is rated as follows:

• 60% – with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months
• 40% – with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months
• 20% – with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months
• 10% – with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months

In this case, VA should apply the rating criteria that results in the higher evaluation for the veteran.

Can Veterans Receive Disability Benefits for Low Back Pain Alone? (Saunders v. Wilkie)

Yes.

In general, veterans need a current, diagnosed condition in order to qualify for VA disability benefits. It can be notoriously difficult to diagnose the exact medical reason for low back pain. As a result, one of the most frequently asked questions that we hear about low back pain is whether pain alone is enough to qualify.

Prior to April 2018, the Court of Appeals for Veterans Claims held that pain alone—without a medical diagnosis of an underlying condition—was not compensable. But in a case called Saunders v. Wilkie, the Federal Circuit ruled that if a veteran experiences back pain as a result of their military service, and the pain causes functional impairment of earning capacity, the veteran may still be eligible to receive VA disability compensation, even if they do not have an actual diagnosis identifying the cause.

The Saunders decision can benefit both veterans seeking service connection and those seeking increased ratings for their back pain.

Potential Factors That Can Increase VA Compensation for Low Back Pain

Flare-Ups of Low Back Pain

If a veteran is service-connected for low back pain, the presence of flare-ups could increase their disability rating.

A flare-up is defined as a sudden and temporary increase in symptoms. Flare-ups are recurrent (i.e., happening repeatedly) but unpredictable and arise without warning. The abrupt escalation in symptoms, including pain and loss of mobility, can sometimes result in additional loss or limitation of motion due to pain during flare-ups. VA should consider this additional loss of movement even if it is not a day-to-day occurrence.

For example, a veteran is granted service connection for a low back condition and receives a 10 percent disability rating. On most days, the veteran is unable to bend forward more than 60 degrees. However, when experiencing a flare-up, the veteran is unable to bend more than 30 degrees. Therefore, during the flare-up, the veteran’s low back condition becomes much more disabling than 10 percent. As such, VA should assign a disability rating that considers this additional functional impairment.

TDIU Benefits Due to Low Back Pain

Veterans who are unable to work due to their service-connected conditions can apply for total disability based on individual unemployability (TDIU). TDIU allows for veterans to be paid at the 100 percent disability rate if their service-connected conditions prevent them from securing and following substantially gainful employment.

While it would be unusual for low back pain alone to qualify a veteran for TDIU, the combination of severe low back pain and other service-connected conditions could potentially qualify.

VA is supposed to automatically consider TDIU if evidence indicates that a veteran may be eligible, but the rules are complex, and many VA claims processors do not have experience with the benefit. Also, veterans who are not aware of TDIU may not know to include related evidence in their claim (for example, statements from their doctor that the veteran’s service-connected conditions are impairing their ability to work). Therefore, veterans who feel they may qualify for TDIU for low back pain are encouraged to contact an experienced VA-accredited representative for assistance with their increased rating claim or appeal.

Aid & Attendance or Housebound Status Due to Low Back Pain (SMC)

Veterans may suffer from low back pain to the point that they require assistance with the activities of daily living or are unable to leave their house. Congress established Special Monthly Compensation (SMC) for situations like this.

As with TDIU, it is unlikely that low back pain alone will meet the qualifications for SMC, but considering low back pain with other conditions may result in the veteran being eligible.

Like TDIU, SMC is a poorly understood VA benefit that even VA claims processors may struggle with. If you feel that you are eligible for SMC due to low back pain or a combination of conditions, contact CCK Law for a free case evaluation.