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Department of Defense

INSTRUCTION


NUMBER 6130.03

April 28, 2010

Incorporating Change 1, September 13, 2011

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USD(P&R)


SUBJECT: Medical Standards for Appointment, Enlistment, or Induction in the Military Services


References: See Enclosure 1


  1. PURPOSE. This Instruction:


    1. Reissues DoD Directive (DoDD) 6130.3 (Reference (a)) as a DoD Instruction (DoDI) in accordance with the authority in DoDD 5124.02 (Reference (b)) to establish policy, assign responsibilities, and prescribe procedures for physical and medical standards for appointment, enlistment, or induction in the Military Services.


    2. Establishes medical standards, which, if not met, are grounds for rejection for military service. Other standards may be prescribed for a mobilization for a national emergency.


    3. Incorporates and cancels DoDI 6130.4 (Reference (c)).


  2. APPLICABILITY. This Instruction applies to:


    1. OSD, the Military Departments (including the Coast Guard at all times, including when it is a service in the Department of Homeland Security by agreement with that Department), the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the Department of Defense (hereafter referred to collectively as the “DoD Components”).


    2. The Reserve Components, which include the Army and the Air National Guards of the United States, in accordance with title 10, United States Code (Reference (d)).


    3. The United States Merchant Marine Academy in accordance with section 310.56 of title 46, Code of Federal Regulations (Reference (e)).


  3. DEFINITIONS. See Glossary.


  4. POLICY. It is DoD policy to:


    1. Utilize common physical standards for the appointment, enlistment, or induction of Service personnel and eliminate inconsistencies and inequities based on race, sex, or location of examination in the application of these standards by the Military Services.


    2. Precisely define any medical condition that causes a personnel action, such as separation, medical waiver, or assignment limitation, by utilizing the International Classification of Diseases (ICD) (Reference (f)), Current Procedural Terminology (CPT) (Reference (g)), and the Healthcare Common Procedure Coding System (HCPCS) (Reference (h)), and annotate qualification decisions by standard medical terminology, rather than codes. The standards in this Instruction shall be for the acquisition of personnel in the Military Services.


    3. Ensure that individuals under consideration for appointment, enlistment, or induction into the Military Services are:


      1. Free of contagious diseases that probably will endanger the health of other personnel.


      2. Free of medical conditions or physical defects that may require excessive time lost from duty for necessary treatment or hospitalization, or probably will result in separation from the Service for medical unfitness.


      3. Medically capable of satisfactorily completing required training.


      4. Medically adaptable to the military environment without the necessity of geographical area limitations.


      5. Medically capable of performing duties without aggravation of existing physical defects or medical conditions.


  5. RESPONSIBILITIES. See Enclosure 2.


  6. PROCEDURES. See Enclosure 3 for Medical and Personnel Executive Steering Committee (MEDPERS) information. Procedures and standards for implementation are in Enclosure 4.


  7. RELEASABILITY. UNLIMITED. This Instruction is approved for public release and is available on the Internet from the DoD Issuances Website at http://www.dtic.mil/whs/directives.

  8. EFFECTIVE DATE. This Instruction is effective immediately.


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Clifford L. Stanley

Under Secretary of Defense for Personnel and Readiness


Enclosures

  1. References

  2. Responsibilities

  3. Medical and Personnel Executive Steering Committee

  4. Medical Standards for Appointment, Enlistment, or Induction Glossary

TABLE OF CONTENTS


ENCLOSURE 1: REFERENCES 6

ENCLOSURE 2: RESPONSIBILITIES 7

PRINCIPAL DEPUTY UNDER SECRETARY OF DEFENSE FOR PERSONNEL

AND READINESS (PDUSD(P&R)) 7

ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS (ASD(HA)) 7

SECRETARIES OF THE MILITARY DEPARTMENTS 7

ENCLOSURE 3: MEDICAL AND PERSONNEL EXECUTIVE STEERING COMMITTEE 9

ENCLOSURE 4: MEDICAL STANDARDS FOR APPOINTMENT, ENLISTMENT, OR INDUCTION 10

GENERAL 10

APPLICABILITY 10

HEAD 10

EYES. 11

VISION 14

EARS 14

HEARING. 14

NOSE, SINUSES, MOUTH, AND LARYNX 15

DENTAL. 16

NECK 16

LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM 16

HEART 18

ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM 21

FEMALE GENITALIA .......................................................................................................2325

MALE GENITALIA............................................................................................................2426

URINARY SYSTEM...........................................................................................................2527

SPINE AND SACROILIAC JOINTS .................................................................................2629

UPPER EXTREMITIES......................................................................................................2730

LOWER EXTREMITIES ....................................................................................................2832 MISCELLANEOUS CONDITIONS OF THE EXTREMITIES.........................................3134 VASCULAR SYSTEM .......................................................................................................3235

SKIN AND CELLULAR TISSUES....................................................................................3336

BLOOD AND BLOOD-FORMING TISSUES...................................................................3437 SYSTEMIC..........................................................................................................................3538 ENDOCRINE AND METABOLIC ....................................................................................3740

RHEUMATOLOGIC 42

NEUROLOGIC....................................................................................................................3843

SLEEP DISORDERS...........................................................................................................4146

LEARNING, PSYCHIATRIC, AND BEHAVIORAL .......................................................4146 TUMORS AND MALIGNANCIES....................................................................................4448

MISCELLANEOUS ............................................................................................................4449


GLOSSARY ..............................................................................................................................4551


ABBREVIATIONS AND ACRONYMS ............................................................................4551 DEFINITIONS.....................................................................................................................4652

ENCLOSURE 1


REFERENCES


  1. DoD Directive 6130.3, “Physical Standards for Appointment, Enlistment, or Induction,” December 15, 2000 (hereby cancelled)

  2. DoD Directive 5124.02, “Under Secretary of Defense for Personnel and Readiness (USD(P&R)),” June 23, 2008

  3. DoD Instruction 6130.4, “Medical Standards for Appointment, Enlistment, or Induction in the Armed Forces,” January 18, 2005 (hereby cancelled)

  4. Title 10, United States Code

  5. Section 310.56 of title 46, Code of Federal Regulations

  6. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-

    CM)1

  7. American Medical Association, Current Procedural Terminology (CPT®), Fourth Edition, 2010 Revision, Chicago, IL, 20102

  8. 2010 Healthcare Common Procedure Coding System (HCPCS) Level II Codes from Centers for Medicare and Medicaid Services (CMS)2

  9. American National Standards Institute ANSI S3.6-2004, “Specification for Audiometers”3

  10. Joint Publication 1-02, “Department of Defense Dictionary of Military and Associated Terms,” current edition



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  1. Available at http://www.cdc.gov/NCHS/icd/icd9cm.htm.

  2. Available at https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp

  3. Available from the American National Standards Institute, 1819 L Street, N.W., Washington, D.C. 20036 or on the Internet at http://www.ansi.org/

ENCLOSURE 2


RESPONSIBILITIES


  1. PRINCIPAL DEPUTY UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS (PDUSD(P&R)). The PDUSD(P&R), under the authority, direction, and control of the Under Secretary of Defense for Personnel and Readiness (USD(P&R)), shall:


    1. Ensure that the standards in Enclosure 4 are implemented throughout the U.S. Military Entrance Processing Command.


    2. Eliminate inconsistencies and inequities based on race, sex, or location of examination in the application of these standards by the Military Services.


    3. Convene the MEDPERS under the joint guidance of the Deputy Under Secretary of Defense for Military Personnel Policy (DUSD(MPP)) and Principal Deputy Assistant Secretary of Defense for Health Affairs (PDASD(HA)). MEDPERS responsibilities are in Enclosure 3.


  2. ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS (ASD(HA)). The ASD(HA), under the authority, direction, and control of the USD(P&R), shall:


    1. Review, approve, and issue to the Secretaries of the Military Departments technical modifications to the standards in Enclosure 4.


    2. Provide guidance to the DoD Medical Examination Review Board to implement the standards in Enclosure 4.


    3. Eliminate inconsistencies and inequities based on race, sex, or location of examination in the application of these standards by the Military Services.


  3. SECRETARIES OF THE MILITARY DEPARTMENTS AND COMMANDANT OF THE COAST GUARD. The Secretaries of the Military Departments and Commandant of the Coast Guard shall:


    1. Direct their respective Services to apply and uniformly implement the standards contained in this Instruction.


    2. Authorize the waiver of the standards in individual cases for applicable reasons and ensure uniform waiver determinations.


    3. Authorize the changes in Service-specific visual standards (particularly for officer accession programs) and establish other standards for special programs. Notification of any

      proposed changes in standards shall be provided to the ASD(HA) at least 60 days before implementation.


    4. Ensure that accurate ICD codes are assigned to all medical conditions resulting in a personnel action, such as separation, waiver, or assignment limitation, and that such codes are included in all records of such actions.


    5. Eliminate inconsistencies and inequities based on race, sex, or examination location in the application of these standards by the Military Services.

ENCLOSURE 3


MEDPERS


  1. MEDPERS convenes quarterly under the joint guidance of the DUSD(MPP) and PDASD(HA).


  2. MEDPERS shall:


    1. Provide policy oversight and guidance to the accession medical and physical standards setting process through the Accession Medical Standards Working Group.


    2. Direct research and studies as necessary to produce evidence-based accession standards utilizing the Accession Medical Standards Analysis and Research Activity.


    3. Ensure medical and personnel community coordination when formulating policy changes that affect each community and other relevant DoD and Department of Homeland Security, and Department of Transportation organizations.

ENCLOSURE 4


MEDICAL STANDARDS FOR APPOINTMENT, ENLISTMENT, OR INDUCTION


  1. APPLICABILITY. The medical standards in this enclosure apply to:


    1. Applicants for appointment as commissioned or warrant officers in the Active and Reserve Components.


    2. Applicants for enlistment in the Military Services. For medical conditions or defects predating original enlistment, these standards apply to enlistees’ first 6 months of active duty.


    3. Applicants for enlistment in the Reserve Components and federally recognized units or organizations of the National Guard. For medical conditions or defects predating original enlistment, these standards apply during the enlistees’ initial period of active duty for training until their return to Reserve or National Guard units.


    4. Applicants for reenlistment in Regular and Reserve Components and in federally recognized units or organizations of the National Guard after a period of more than 12 months have elapsed since discharge.


    5. Applicants for the Scholarship or Advanced Course Reserve Officer Training Corps (ROTC), and all other Military Services’ special officer personnel procurement programs.


    6. Cadets and midshipmen at the U.S. Service academies and students enrolled in ROTC scholarship programs applying for retention in their respective programs.


    7. Individuals on the Temporary Disability Retired List (TDRL) who have been found fit on reevaluation by the Physical Disability Evaluation System (PDES) and who elect to return to active duty or to active status in the Reserve Components within the time standards prescribed by Service Regulations. These individuals are exempt from this Instruction for the conditions for which they were found fit on reevaluation by the PDES.


    8. All individuals being inducted into the Military Services.


  2. MEDICAL STANDARDS. Throughout this enclosure, ICD, CPT and HCPCS codes are included with most medical conditions and procedures, usually parenthetically, to aid cross- referencing. Unless otherwise stipulated, the conditions listed in this enclosure are those that do NOT meet the standard by virtue of current diagnosis, or for which the candidate has a verified past medical history. The medical standards for appointment, enlistment, or induction into the Military Services are classified by the general systems described in sections 3-3031 of this enclosure.

  3. HEAD


    1. Deformities of the skull, face, or mandible (738.19, 744.9, 754.0) of a degree that shall prevent the individual from the proper wearing of a protective mask or military headgear.


    2. Loss, or absence of the bony substance of the skull (756.0 or 738.19) not successfully corrected by reconstructive materials, or leaving any residual defect in excess of 1 square inch (6.45 square centimeters), or the size of a 25-cent piece.


  4. EYES


    1. Lids


      1. Current symptomatic blepharitis (373.0x).


      2. Current blepharospasm (333.81).


      3. Current dacryocystitis, acute (375.32), or chronic (375.42).


      4. Defect or deformity of the lids or other disorders affecting eyelid function (374.4x, 374.50, 374.85, 374.89, 743.62), complete, or significant ptosis (374.3x, 743.61), sufficient to interfere with vision or impair protection of the eye from exposure.


        (5) Current growths or tumors of the eyelid (173.1, 198.2, 216.1, 232.1, 238.8, 239.89), other than small, non-progressive, asymptomatic, benign lesions.


    2. Conjunctiva


      1. Current acute or chronic conjunctivitis (372.1x, 077.0). Seasonal allergic conjunctivitis (372.14) DOES meet the standard.


      2. Current pterygium (372.4x) if condition encroaches on the cornea in excess of 3 millimeters, interferes with vision, is progressive, or a history of recurrence after any prior surgical removal (372.45).


    3. Cornea


      1. Corneal dystrophy or degeneration of any type (371.x), including but not limited to keratoconus (371.6x) of any degree.


      2. History of any incisional corneal surgery including, but not limited to, partial or full thickness corneal transplant, radial keratotomy (RK), astigmatic keratotomy (AK), or corneal implants (Intacs®)

      3. Corneal refractive surgery performed with an excimer laser, including but not limited to photorefractive keratectomy (PRK) (HCPCS S0810), laser epithelial keratomileusis (LASEK), and laser-assisted in situ keratomileusis (LASIK) (HCPCS S0900) (ICD-9 code for each is P11.7) if any of the following conditions are met:


        1. Pre-surgical refractive error in either eye exceeded a spherical equivalent of +8.00 or -8.00 diopters.


        2. Pre-surgical astigmatism exceeded 3.00 diopters.


        3. For corneal refractive surgery, at least 180 days recovery period has not occurred between last refractive surgery or augmenting procedure and accession medical examination.


        4. There have been complications and/or medications or ophthalmic solutions, or any other therapeutic interventions such as sunglasses, are required.


        5. Post-surgical refraction in each eye is not stable as demonstrated by at least two separate refractions at least 1 month apart, with initial refraction at least 90 days post-procedure, and the most recent of which demonstrates more than +/- 0.50 diopters difference for spherical vision and/or more than +/- 0.50 diopters for cylinder vision.


      4. Current or recurrent keratitis (370.xx)


      5. Documented herpes simplex virus keratitis (054.42, 054.43).


      6. Current corneal neovascularization, unspecified (370.60), or corneal opacification (371.00, 371.03) from any cause that is progressive or reduces vision below the standards prescribed in this Instruction.


      7. Current or history of uveitis or iridocyclitis (364.00-364.3).


    4. Retina


      1. Current or history of any abnormality of the retina (361.00-362.89, 363.14-363.22), choroid (363.00-363.9) or vitreous (379.2x).


    5. Optic Nerve


      1. Any current or history of optic nerve disease (377.3), including but not limited to optic nerve inflammation (363.05), optic nerve swelling, or optic nerve atrophy (377.12, 377.14).


      2. Any optic nerve anomaly.


    6. Lens

      1. Current aphakia (379.31, 743.35), history of lens implant (V45.61, V43.1) (CPT 66982-66986), or current or history of dislocation of a lens (379.32-379.34, 743.37).


      2. Current or history of opacities of the lens (366.xx), including cataract (366.9).


    7. Ocular Mobility and Motility


      1. Current or recurrent diplopia (368.2).


      2. Current nystagmus (379.5x) other than physiologic “end-point nystagmus.”


      3. Esotropia (378.0x), exotropia (378.1x), and hypertropia (378.31): For entrance into Service academies and officer programs, the individual Military Services may set additional requirements. The Military Services shall determine special administrative criteria for assignment to certain specialties.


    8. Miscellaneous Defects and Diseases


      1. Current or history of abnormal visual fields (368.9) due to diseases of the eye or central nervous system (368.4x), or trauma.


      2. Absence of an eye (V43.0, V45.78), clinical anophthalmos, unspecified congenital (743.00) or acquired, or current or history of other disorders of globe (360.xx).


      3. Current unilateral or bilateral exophthalmoses (376.21-376.36).


      4. Current or history of glaucoma (365.xx), ocular hypertension, pre-glaucoma (365.0- 365.04), or glaucoma suspect.


      5. Any abnormal pupillary reaction to light (379.4x) or accommodation (367.5x).


      6. Asymmetry of pupil size greater than 2mm.


      7. Current night blindness (264.5, 368.6x).


      8. Current or history of intraocular foreign body (360.50-360.69, 871.x).


        (9) Current or history of ocular tumors (190.0, 190.8-190.9, 198.4, 224.0, 224.8-224.9,

        234.0, 238.8, 239.89, V10.84).


        (10) Current or history of any abnormality of the eye (360) or adnexa (376, 379.9), not specified in subparagraphs 4.h.(1)-(9) of this enclosure, which threatens vision or visual function V41.0-V41.1, V52.2, V59.5).

  5. VISION


    1. Current distant visual acuity of any degree that does not correct with spectacle lenses to at least one of the following (367):


      1. 20/40 in one eye and 20/70 in the other eye (369.75).


      2. 20/30 in one eye and 20/100 in the other eye (369.75).


      3. 20/20 in one eye and 20/400 in the other eye (369.73).


    2. Current near visual acuity of any degree that does not correct to 20/40 in the better eye (367.1-367.32).


    3. Current refractive error (hyperopia (367.0), myopia (367.1), astigmatism (367.2x)), in excess of -8.00 or +8.00 diopters spherical equivalent or astigmatism in excess of 3.00 diopters.


    4. Any condition requiring contact lenses for adequate correction of vision, such as corneal scars and opacities (370.0x) and irregular astigmatism (367.22).


    5. Color vision (368.5x) requirements shall be set by the individual Services.


  6. EARS


    1. Current atresia of the external ear (744.02) or severe microtia (744.23), congenital or acquired stenosis (380.5x), chronic otitis externa (380.15-380.16, 380.23), or severe external ear deformity (380.32, 738.7, 744.01, 744.3) that prevents or interferes with the proper wearing of hearing protection.


    2. Current or history of Ménière’s Syndrome or other chronic diseases of the vestibular system (386.xx).


    3. History of cochlear implant.


    4. Current or history of cholesteatoma (385.3x)


    5. History of any inner (P20) (CPT 69801-69930) or middle (P19) (CPT 69631-69636, 69676) ear surgery excluding successful tympanoplasty (CPT 69635) performed during the preceding 180 days.


    6. Current perforation of the tympanic membrane (384.2x) or history of surgery to correct perforation during the preceding 180 days (P19) (CPT 69433, 69436, 69610, 69631-69646).


    7. Chronic Eustachian tube dysfunction as evidenced by retracted tympanic membrane, or recurrent otitis media, or the need for pressure-equalization (PE) tube within the last 3 years.


  7. HEARING All hearing defects are coded with ICD-9 code 389.xx.


    1. Audiometric hearing levels are measured by audiometers calibrated to the standards in American National Standards Institute (ANSI S3.6-2004) (Reference (i)) and shall be used to test the hearing of all applicants.


    2. Current hearing threshold level in either ear greater than that described in subparagraphs 7.b.(1)-(3) of this enclosure does not meet the standard:


      1. Pure tone at 500, 1000, and 2000 cycles per second for each ear of not more than 30 decibels (dB) on the average with no individual level greater than 35 dB at those frequencies.


      2. Pure tone level not more than 45 dB at 3000 cycles per second or 55 dB at 4000 cycles per second for each ear.


      3. There is no standard for 6000 cycles per second.


    3. Current or history of hearing aid use (V53.2).


  1. NOSE, SINUSES, MOUTH, AND LARYNX


    1. Current cleft lip or palate defects (749.xx) not satisfactorily repaired by surgery or that interfere with use or wear of military equipment, or that prevent drinking from a straw.


    2. Current ulceration of oral mucosa, including tongue (528.6), excluding apthous ulcers.


    3. Current chronic conditions of larynx including vocal cord paralysis (478.3x) or history of laryngeal papillomatosis.


    4. History of non-benign polyps, (478.4) chronic hoarseness (78.49), chronic laryngitis (476.0) or spasmodic dysphonia.


    5. Current anosmia or parosmia (781.1).


    6. History of recurrent epistaxis with more than one episode per week of bright red blood from the nose occurring over a 3-month period (784.7) within the last 3 years.


    7. Current nasal polyp or history of nasal polyps (471.x), unless more than 12 months have elapsed since nasal polypectomy (CPT 30110, 30115, 31237-31240) and/or sinus surgery, and asymptomatic.


    8. Current perforation of nasal septum (478.1, 478.19, 748.1).

    9. Current chronic sinusitis (473) as evidenced by chronic purulent discharge, symptoms requiring frequent medical attention, or computed tomography (CT) scan.


    10. Current or history of deformities, or conditions or anomalies of the upper alimentary tract (750.9), mouth (750.26), tongue (750.1x), palate, throat, pharynx, larynx (748.3), and nose (748.1), that interfere with chewing (V41.6), swallowing, speech, or breathing.


  2. DENTAL


    1. Current diseases or pathology of the jaws or associated tissues that prevent normal functioning. Those diseases or conditions include but are not limited to temporomandibular disorders (524.6x) and/or myofascial pain (784.0). A minimum of 6 months healing time must elapse for any individuals completing surgical treatment of any maxillofacial pathology lesions.


    2. Current severe malocclusion (524.00-524.29, 524.4), which interferes with normal chewing or requires immediate and protracted treatment, or a relationship between the mandible and maxilla that prevents satisfactory future prosthodontic replacement.


    3. Eight or more grossly (visually) cavitated and/or carious teeth (521.0x). Applicants who are edentulous must have functioning dentures. Lack of a serviceable prosthesis that prevents adequate biting and chewing of a normal diet. Individuals undergoing endodontic care are acceptable for entry into the Delayed Entry Program (DEP) only if a civilian or military dentist or endodontist provides documentation that active endodontic treatment shall be completed prior to being sworn to active duty.


    4. Current orthodontic appliances (mounted or removable, i.e., Invisalign®) for continued active treatment (V53.4). Permanent or removable retainers are permissible. Individuals undergoing active orthodontic care are acceptable for accession (including DEP) only if a civilian or military orthodontist provides documentation that active orthodontic treatment shall be completed prior to being sworn into active duty. Entrance to active duty will not occur until all orthodontic treatment is documented to be completed.


  3. NECK


    1. Current symptomatic cervical ribs (756.2).


    2. Current congenital cyst(s) (744.4x) of branchial cleft origin or those developing from the remnants of the thyroglossal duct (759.2).


    3. Current contraction (723.5, 754.1)) of the muscles of the neck, spastic or non-spastic, or cicatricial contracture of the neck to the extent it interferes with the proper wearing of a uniform or military equipment, or is so disfiguring as to interfere with or prevent satisfactory performance of military duty.


  1. LUNGS, CHEST WALL, PLEURA, AND MEDIASTINUM


    1. Current abnormal elevation of the diaphragm (either side) (756.6). Any nonspecific abnormal findings on radiological and other examination of body structure, such as lung field (793.1) or other thoracic or abdominal organ (793.2).


    2. Current abscess of the lung (513.0) or mediastinum (513.1).


    3. Current or history of recurrent acute infectious processes of the lung, including but not limited to viral pneumonia (480.x), pneumococcal pneumonia (481), bacterial pneumonia (482.xx), pneumonia due to other specified organism (483.x), pneumonia infectious disease classified elsewhere (484.x), bronchopneumonia (organism unspecified) (485), and pneumonia (organism unspecified) (486).


    4. Airway hyper responsiveness including asthma (493.xx), reactive airway disease, exercise-induced bronchospasm (519.11) or asthmatic bronchitis (493.90), reliably diagnosed and symptomatic after the 13th birthday.


      1. Reliable diagnostic criteria may include any of the following elements: substantiated history of cough, wheeze, chest tightness, and/or dyspnea which persists or recurs over a prolonged period of time, generally more than 12 months.


      2. Individuals DO MEET the standard if within the past 3 years they meet ALL of the criteria in subparagraphs 11.d.(2)(a)-(d).


        1. No use of controller or rescue medications (including, but not limited to inhaled corticosteroids, leukotriene receptor antagonists, or short-acting beta agonists).


        2. No exacerbations requiring acute medical treatment.


        3. No use of oral steroids.


        4. A current normal spirometry (within the past 90 days), performed in accordance with American Thoracic Society (ATS) guidelines and as defined by current National Heart, Lung, and Blood Institute (NHLBI) standards.


    5. Chronic obstructive pulmonary disease (491).


      1. Current or history of bullous or generalized pulmonary emphysema (492).


      2. Current bronchitis (490), acute or chronic symptoms over 3 months occurring at least twice a year (491).


    6. Current or history of bronchiectasis (494). Bronchiectasis during the first year of life is not disqualifying if there are no residual or sequelae.


    7. Current or history of bronchopleural fistula (510.0), unless resolved with no sequelae.


    8. Current chest wall malformation (754.89), including but not limited to pectus excavatum (754.81) or pectus carinatum (754.82), if these conditions interfere with vigorous physical exertion.


    9. History of empyema (510.9).


    10. Pulmonary fibrosis (515).


    11. Current foreign body in lung (934.8, 934.9), trachea (934.0), or bronchus (934.1).


      l. History of thoracic surgery (32-33), (CPT 32035-32999, 33010-33999, 43020-43499) including open and endoscopic procedures.


      1. Current or history of pleurisy with effusion (511.9) within the previous 2 years.


      2. Current or history of pneumothorax (512) occurring during the year preceding examination if due to trauma (860) or surgery, or occurring during the 2 years preceding examination from spontaneous (512.8 ) origin.


      3. Recurrent spontaneous pneumothorax (512.8).


      4. History of chest wall surgery (34-34.9), including breast (85-85.9), during the preceding 6 months, or with persistent functional limitations.


  2. HEART


    1. History of valvular repair or replacement (CPT 33400-33478).


      1. Current or history of the following valvular conditions as defined by the current American College of Cardiology and American Heart Association guidelines:


        1. Severe pulmonic regurgitation.


        2. Severe tricuspid regurgitation.


        3. Moderate pulmonic regurgitation unless documented mean pulmonary artery pressure is less than 25 mmHg.


        4. Moderate tricuspid regurgitation unless documented mean pulmonary artery pressure is less than 25 mmHg.


        5. Moderate or severe mitral regurgitation.


        6. Mild, moderate, or severe aortic regurgitation.


      2. The following are considered normal variants that meet accession standards:


        1. Trace or mild pulmonic regurgitation.


        2. Trace or mild tricuspid regurgitation.


        3. Trace or mild mitral regurgitation in the absence of mitral valve prolapse.


        4. Trace aortic insufficiency.


    2. Mitral valve prolapsed (396.3) with normal exercise tolerance not requiring medical therapy DOES meet the standard.


    3. Bicuspid aortic valve (746.4), in the absence of stenosis or regurgitation as in

      subparagraphs 12.a.(1)(a)-(f), DOES meet the standard.


    4. All valvular stenosis (396).


    5. Current or history of atherosclerotic coronary artery disease (410).


    6. Current or history of pacemaker or defibrillator implantation (CPT 3320-33249).


    7. History of supraventricular tachycardia (427.0).


      1. History of recurrent atrial fibrillation (427.31) or flutter (427.32).


      2. Supraventricular tachycardia (427.0) associated with an identifiable reversible cause and no recurrence during the preceding 2 years while off all medications DOES meet the standard.


      3. Those with identified atrioventricular nodal reentrant tachycardia or atrioventricular reentrant tachycardia (such as Wolff-Parkinson-White (WPW) syndrome) (426.7) who have undergone successful ablative therapy with no recurrence of symptoms after 3 months and with documentation of normal electrocardiograph (ECG) meet the standard.


    8. Premature atrial or ventricular contractions sufficiently symptomatic to require treatment, or result in physical or psychological impairment.


    9. Abnormal ECG patterns (794.31): (1) Long QT (426.82).

      1. Brugada pattern.


      2. WPW syndrome (426.7) pattern unless associated with low risk accessory pathway by appropriate diagnostic testing.


    10. Current or history of ventricular arrhythmias (427.1) including ventricular fibrillation, tachycardia, or multifocal premature ventricular contractions. Occasional asymptomatic unifocal premature ventricular contractions meet the standard.


    11. Current or history of conduction disorders, including but not limited to disorders of sinus arrest, asystole, Mobitz type II second-degree atrioventricular (AV) block (426.12), and third- degree AV block (426.0).


    12. In the absence of cardiovascular symptoms, the following meet the standard:


      1. Sinus arrhythmia.


      2. First degree AV block (426.11).


      3. Left axis deviation of less than -45 degrees.


      4. Early repolarization.


      5. Incomplete right bundle branch block.


      6. Wandering atrial pacemaker (427.89) or ectopic atrial rhythm (427.89).


      7. Sinus bradycardia (427.81).


      8. Mobitz type I second-degree AV block (426.13).


    13. Current or history of conduction disturbances such as left anterior hemiblock (426.2), right or left bundle branch block (426.4) do not meet the standard unless asymptomatic with a normal echocardiogram.


    14. Current or history of cardiomyopathy (425), cardiomegaly, hypertrophy (defined as septal wall thickness of 15 mm or greater), dilation (429.3), or congestive heart failure (428).


    15. History of myocarditis (422) or pericarditis (420) unless the individual is free of all cardiac symptoms, does not require medical therapy, and has normal echocardiography for at least 1 year.


    16. Current persistent tachycardia (785.0) (as evidenced by average heart rate of 100 beats per minute or greater over a 24-hour period of continuous monitoring).

    17. Current or history of congenital anomalies of heart and great vessels (746). The following conditions meet the standard with an otherwise normal current (within 6 months) echocardiogram.


      1. Dextrocardia (746.87) with situs inversus (759.3) without any other anomalies.


      2. Ligated or occluded patent ductus arteriosus (747.0).


      3. Corrected atrial septal defect (745.9) or patent foramen ovale (745.5) without residua.


      4. Corrected ventricular septal defect (745.4) without residua.


    18. History of recurrent syncope and or presyncope (780.2), including black out, fainting, loss or alteration of level of consciousness (excludes vasovagal reactions with identified trigger such as venipuncture) unless there has been no recurrence during the preceding 2 years while off all medication.


    19. Unexplained ongoing or recurring cardiopulmonary symptoms (to include but not limited to syncope, presyncope, chest pain, palpitations, and dyspnea on exertion) that impairs a physically active lifestyle.


    20. History of rheumatic fever (390).


  3. ABDOMINAL ORGANS AND GASTROINTESTINAL SYSTEM


    1. Esophageal Disease


      1. Current or history of esophageal disease (530.0-530-9), including but not limited to ulceration, varices, fistula, or achalasia.


      2. Gastro-Esophageal Reflux Disease (GERD) (530.81), with complications, including stricture, or maintenance on acid suppression medication, other dysmotility disorders; or chronic or recurrent esophagitis (530.1).


        1. Stricture or B-ring.


        2. Dysphagia.


        3. Recurrent symptoms or esophagitis despite maintenance medication.


        4. Barrett’s esophagitis.


        5. Extraesophageal complications; reactive airway disease; recurrent sinusitis or dental complications.


      3. Current or history of reactive airway disease associated with GERD (530.81).


        (43) History of surgical correction (fundoplication or dilation) for GERD within 6 months (P42-esophageal correction, P43-stomach correction, and P45-intestinal correction) (CPT 43257)(45.89).


        (54) Current or history of dysmotility disorders and chronic or recurrent esophagitis (530)., to include diffuse esophageal spasm, nutcracker esophagus, non-specific motility disorder, and achalasia.


        1. Eosinophilic esophagitis.


        2. Other esophageal strictures, for example lye or other caustic ingestion.


    2. Stomach and Duodenum


      1. Current gastritis, chronic or severe (535), or non-ulcerative dyspepsia that requires maintenance medication dyspepsia requiring medication; or history of dyspepsia lasting 3 or more consecutive months and requiring medication within the preceding 12 months.


      2. Current or history of ulcer of the stomach or duodenum confirmed by X-ray or endoscopy (533). Gastric or duodenal ulcers:


        1. Current ulcer or history of treated ulcer within the last 3 months.


        2. Recurrent or complicated by bleeding, obstruction, or perforation within preceding 5 years confirmed by endoscopy.


      3. History of surgery for peptic ulceration or perforation (533.0-599.9).


        1. History of gastroparesis.


        2. History of bariatric surgery of any type (e.g., lap-band or gastric bypass surgery for weight loss).


        3. History of gastric varices.


    3. Small and Large Intestine


      1. Current or history of inflammatory bowel disease, including but not limited to unspecified indeterminate (558.9), regional enteritis or Crohn’s disease (555), ulcerative colitis (556), or ulcerative proctitis (556.2).


        (2) Current infectious colitis not otherwise specified (009.1).


        (23) Current or history of intestinal malabsorption syndromes (579.9), including but not limited to celiac sprue, pancreatic insufficiency, post-surgical and idiopathic (579). Lactase

        deficiency does not meet the standard only if of sufficient severity to require frequent intervention, or to interfere with normal function.


        (34) Current or history of gastrointestinal functional and motility disorders within the past 2 years, including but not limited to pseudo-obstruction, megacolon, history of volvulus, or chronic constipation (564.0) and or diarrhea (787.91), regardless of cause, persisting or symptomatic in the past 2 years.


        (45) History of gastrointestinal bleeding (578), including positive occult blood (792.1), if the cause has not been corrected. Meckel’s diverticulum (751.0), if surgically corrected more than 6 months prior DOES meet the standard.


        (56) Current or history of irritable bowel syndrome (564.1) of sufficient severity to require frequent intervention or prescription medication or to interfere with normal function.


        (67) History of bowel resection (CPT 44202-44203).


        (78) Current or history of symptomatic diverticular disease of the intestine (562).


        (9) Personal or family history of familial adenomatous polyposis syndrome or hereditary non-polyposis colon cancer syndrome.


    4. Hepatic-Biliary Tract


      1. Current acute or chronic hepatitis, hepatitis carrier state (070), hepatitis in the preceding 6 months or persistence of symptoms after 6 months, or objective evidence of impairment of liver function.


      2. Current or history of cirrhosis (571), hepatic cysts (573.8), abscess (572.0), or sequelae of chronic liver disease (571.3).


      3. Current or history of symptomatic cholecystitis (575.10), unless successfully surgically corrected, acute or chronic, with or without cholelithiasis (574); postcholecystectomy syndrome; or other disorders of the gallbladder and biliary system (576). Cholecystectomy DOES meet the standard if performed more than 6 months prior to examination and patient remains asymptomatic. Fiberoptic Endoscopic procedure to correct sphincter dysfunction or cholelithiasis choledocholithiasis, if performed more than 6 months prior to examination and patient remains asymptomatic, MAY meet the standard.


        1. History of sphincter of Oddi dysfunction.


        2. Choledochocyst.


        3. Primary biliary cirrhosis or primary sclerosing cholangitis.


        (47) Current or history of pancreatitis, acute (577.0) or chronic (577.1).


        1. Pancreatic cyst.


        2. History of pancreatic surgery.


        (510) Current or history of metabolic liver disease, including but not limited to hemochromatosis (275.0), Wilson’s disease (275.1), or alpha-1 anti-trypsin deficiency (273.4). Gilbert’s syndrome DOES meet the standard.


        (611) Current enlargement of the liver from any cause (789.1).


    5. Anorectal


      1. Current anal fissure or anal fistula (565).


      2. Current or history of anal or rectal polyp (569.0), prolapse (569.1), stricture (569.2), or fecal incontinence (787.6), within the last 2 years. History of removal of juvenile or inflammatory polyp DOES meet the standard.


      3. Current hemorrhoid (internal or external), when large, symptomatic, or with a history of bleeding (455) within the last 60 days.


    6. Spleen


      1. Current splenomegaly (789.2).


      2. History of splenectomy (P41.5) (CPT 38100-38129), except when resulting from trauma.


        gf. Abdominal Wall


        1. Current hernia (except for small or asymptomatic umbilical hernias), including but not limited to uncorrected inguinal (550) and other abdominal wall hernias (553).


        2. History of open or laparoscopic abdominal surgery (CPT 22900-22999, 43500- 49999) during the preceding 6 months (P54). Uncomplicated laparoscopic appendectomies (CPT 44970) meet the standard after 3 months.


        hg. Obesity. History of any gastrointestinal procedure for the control of obesity (CPT 43644-43645, 43770-43775, 43842-43848, 43886-43888) or artificial openings, including but not limited to ostomy (V44).

  4. FEMALE GENITALIA


    1. Current or history of abnormal uterine bleeding (626.2) menstruation unresponsive to medical management within the last 12 months, including but not limited to menorrhagia, metrorrhagia, or polymenorrhea.


    2. Current unexplained Primary amenorrhea (626.0).


      c. Current unexplained secondary amenorrhea (626.0).


      cd. Current or history of dysmenorrhea (625.3) that is unresponsive to medical therapy and is incapacitating to a degree recurrently necessitating requiring absences of more than a few hours from routine activities.

      de. Current or history of eEndometriosis (617) that is unresponsive to medical therapy. ef. History of major abnormalities or defects of the genitalia such as including but not

      limited to change of sex (P64.5) (CPT 55970, 55980), hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis (752.7).


      image

      fg. Current or history of Persistent or clinically significant ovarian cyst(s) (620.2) when persistent or symptomatic.


      h. Polycystic ovarian syndrome (256.4) with metabolic complications.


      gi. Current pPelvic inflammatory disease (614) or history of recurrent pelvic inflammatory disease. Current or history of chronic pelvic pain or unspecified symptoms associated with female genital organs (625.9) within the preceding 30 days.


      j. Chronic pelvic pain or unspecified symptoms associated with female genital organs (625.9).


      hk. Current pPregnancy (V22), until through 6 months after the end completion of the pregnancy (CPT 59150, 59151, 59400, 59409, 59510, 59514, 59610, 59612, 59812-59857).


      1. History of congenital absence of the uterus (752.3).


        image

        jl. Current Symptomatic uterine enlargement due to any cause (621.2).


        km. Current or history of genital infection or ulceration, including but not limited to herpes genitalis (054.11) or condyloma acuminatum (078.11), if of sufficient severity requiring to require frequent intervention or to interfere with normal function. Herpes does not meet the standard if:


        1. Current lesions are present.

        2. Chronic suppressive therapy is needed.


        3. There are three or more outbreaks per year.


        4. Any outbreak in the past 12 months interfered with normal function.


        5. Treatment included hospitalization or intravenous therapy.


      image

      ln. Current or history of aAbnormal gynecologic cytology within the preceding 2 years, including but not limited to unspecified abnormalities of the Papanicolaou smear of the cervix (795.0), excluding atypical squamous cells of undetermined significance without human papillomavirus (079.4) and confirmed low-grade squamous intraepithelial lesion (622.9). For the purposes of this Instruction, confirmation is by colposcopy or repeat cytology.


  5. MALE GENITALIA


    1. Absence of one or both testicles, congenital (752.89) or undescended (752.51). Unilateral loss of a testis, unrelated to cancer, DOES meet the standard.


    2. Current or history of epispadias (752.62) or hypospadias (752.61), when accompanied by evidence of urinary tract infection, urethral stricture, or voiding dysfunction.


      1. Current or history of surgery for proximal hypospadias (752.61).


      2. Distal (coronal) hypospadias without history of surgery DOES meet the standard.


      3. Distal (coronal) hypospadias treated with surgery when accompanied by evidence of urinary tract infection, urethral stricture, or voiding dysfunction.


      cf. Current enlargement or mass of testicle or, epididymis (608.9), or spermatic cord. dg. Current or history of recurrent orchitis or epididymitis (604.90).

      eh. History of penis amputation (878.0) (CPT 54125, 54130-54135).


      1. Current penile curvature if associated with pain.


        image

        fj. Current or history of genital infection or ulceration, including but not limited to herpes genitalis (054.13) or condyloma acuminatum (078.11), if of sufficient severity to require frequent intervention or to interfere with normal function. Herpes does not meet the standard if:


        1. Current lesions are present.


        2. Use of chronic suppressive therapy is needed.

        3. There are three or more outbreaks per year.


        4. Any outbreak in the past 12 months interfered with normal function.


        5. Treatment included hospitalization or intravenous therapy.


      k. Current or history of urethral condyloma acuminatum.


      gl. Current acute prostatitis (601.0) or, chronic prostatitis (601.1), or chronic pelvic pain syndrome.


      hm. Current hydrocele (603) with greatest dimension of 4 centimeters or greater or symptomatic or spermatacele associated with pain or which precludes a complete exam of the scrotal contents.


      image

      in. Left varicocele (456.4), if painful or symptomatic, or associated with testicular atrophy, or varicocele larger than the testis.


      o. Left varicocele (456.4) that does not reduce or decompress completely when supine.


      image

      jp. Any Bilateral or right varicocele (456.4).


      kq. Current or history of chronic or recurrent scrotal pain or unspecified symptoms associated with male genital organs (608.9).


      image

      lr. History of major abnormalities or defects of the genitalia such as change of sex (P64.5) (CPT 55970, 55980), hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis (752.7).


  6. URINARY SYSTEM


    1. Current cystitis, or history of chronic or/ recurrent cystitis (595), interstitial cystitis, or painful bladder syndrome.


    2. Current urethritis, or history of chronic or recurrent urethritis (597.80).


    3. History of enuresis (788.30) or incontinence of urine (788.30), or the control of it with medication or other treatment past the 15th birthday. or treatment of the following voiding symptoms within the previous 12 months:


      1. Urinary frequency or urgency more than every 2 hours on a daily basis.


      2. Nocturia more than two episodes during sleep period.


        (3) Enuresis (788.30).


        1. Incontinence of urine, such as urge or stress.


        2. Urinary retention.


        3. Dysuria.


        1. History of need for urinary catheterization with intermittent or indwelling catheter for any period greater than 2 weeks.


        2. History of bladder augmentation, urinary diversion, or urinary tract reconstruction.


          df. Current hematuria (599.7), pyuria, or other findings indicative of urinary tract disease (599). or history of abnormal urinary findings:


          1. Gross hematuria (599.7).


          2. Microscopic hematuria (3 or more red blood cells per high-powered field on 2 of 3 properly collected urinalyses).


          3. Pyuria (6 or more white blood cells per high-powered field in 2 or 3 properly collected urinalyses).


        eg. Current or recurrent urethral or ureteral stricture (598) or fistula (599.1) involving the urinary tract.


        image

        fh. Conditions associated with the kidneys, including:


        (1) Current absence of one kidney, congenital (753.0) or acquired (V45.73) (CPT 50220- 50236).


        1. Asymmetry in size or function of kidneys.


        2. History of renal transplant.


        (24) Current chronic or recurrent pyelonephritis (590.0) (chronic or recurrent), or any other unspecified infections of the kidney (590.9).


        (35) Current or history of polycystic kidney (753.1).


        (46) Current or history of horseshoe kidney (753.3).


        (57) Current or history of hydronephrosis (591).


        (68) Current or history of acute (580) nephritis or chronic (582) nephritis kidney disease

        of any type.


        (9) History of acute kidney injury requiring dialysis.


        (710) Current or history of proteinuria (791.0) greater than 200 milligrams in 24 hours or with a protein-to-creatinine ratio greater than 0.2 in a random urine sample, if greater more than 48 hours after strenuous activity, unless consultation determines the condition to be benign orthostatic proteinuria. Benign orthostatic proteinuria MEETS the standard.


        (811) Current or history of symptomatic urolithiasis (592) within the preceding 12 months. Recurrent calculus, nephrocalcinosis, or bilateral renal calculi at any time.


        1. History of stone(s) greater than 4mm in size, recurrent calculus, nephrocalcinosis, or bilateral renal calculi at any time.


        2. History of urolithiasis requiring surgical treatment or intervention requiring hospitalization.


  7. SPINE AND SACROILIAC JOINTS


    1. Ankylosing spondylitis or other inflammatory spondylopathies (720).


    2. Current or history of any condition, including but not limited to the spine or sacroiliac joints, with or without objective signs, if:


      1. It prevents the individual from successfully following a physically active vocation in civilian life (724), or is associated with local or referred pain to the extremities, muscular spasms, postural deformities, or limitation in motion.


      2. It requires external support.


      3. It requires limitation of physical activity or frequent treatment.


    3. Current deviation or curvature of spine (737) from normal alignment, structure, or function if:


      1. It prevents the individual from following a physically active vocation in civilian life.


      2. It interferes with the proper wearing of a uniform or military equipment.


      3. It is symptomatic.


      4. There is lumbar or thoracic scoliosis greater than 30 degrees, or kyphosis and lordosis greater than 50 degrees when measured by the Cobb Method.

    4. History of congenital fusion (756.15) involving more than two vertebral bodies or any surgical fusion of spinal vertebrae (P81.0) (CPT 22532-22812).


    5. Current or history of fracture or dislocation of the vertebra (805).


      1. Vertebral fractures that do NOT meet the standard:



        vertebra.

        1. Compression fractures involving more than or equal to 25 percent of a single


        2. Compression fractures involving less than 25 percent of a single vertebra occurring within the past 12 months or it is symptomatic.


        3. Any compression fracture that is symptomatic.


      2. Vertebral fractures that DO MEET the standard:


        1. Compression fractures involving less than 25 percent of a single vertebra if it occurred more than 1 year before the accession examination and the applicant is asymptomatic.


        2. A history of fractures of the transverse or spinous process IF the applicant is asymptomatic.


    6. History of juvenile epiphysitis (732.6) with any degree of residual change indicated by X- ray or kyphosis.


    7. Current herniated nucleus pulposus (722) or history of surgery to correct (CPT 63001- 63200). A surgically corrected asymptomatic single-level lumbar or thoracic diskectomy with full resumption of unrestricted activity DOES meet the standard.


    8. Current or history of spina bifida (741) when symptomatic, when there is more than one vertebral level involved, or with dimpling of the overlying skin. History of surgical repair of spina bifida.


    9. Current or history of spondylolysis congenital (756.10-756.12) or acquired (738.4).


    10. Current or history of spondylolisthesis congenital (756.12) or acquired (738.4).


  8. UPPER EXTREMITIES


    1. Limitation of Motion. Current active joint ranges of motion less than:


      1. Shoulder (726.1)


        1. Forward elevation to 90 degrees.


        2. Abduction to 90 degrees. (2) Elbow (726.3)

          1. Flexion to 130 degrees.


          2. Extension to 15 degrees.


          1. Wrist (726.4). A total range of 60 degrees (extension plus flexion), or radial and ulnar deviation combined arc 30 degrees.


            (4) Hand (726.4)


            1. Pronation to 45 degrees.


            2. Supination to 45 degrees.


          (5) Fingers and Thumb (726.4). Inability to clench fist, pick up a pin, grasp an object, or touch tips of at least three fingers with thumb.


    2. Hand and Fingers


      1. Absence of the distal phalanx of either thumb (885).


      2. Absence of any portion of the index finger.


      3. Absence of distal and middle phalanx of the middle or ring finger of either hand irrespective of the absence of the little finger (886).


      4. Absence of more than the distal phalanx of any two of the following: index, middle, or ring finger of either hand (886).


      5. Absence of hand or any portion thereof (887), except for specific absence of fingers as noted in subparagraphs 18.b.(1)-(4).


      6. Current polydactyly (755.0).


      7. Intrinsic paralysis or weakness of upper limbs, including but not limited to nerve paralysis, carpal tunnel and cubital syndromes, lesion of ulnar, median, or radial nerve (354), sufficient to produce physical findings in the hand such as muscle atrophy and weakness.


    3. Residual Weakness and Pain. Current disease, injury, or congenital condition with residual weakness or symptoms that prevents satisfactory performance of duty, including but not limited to chronic joint pain associated with the shoulder (719.41), the upper arm (719.42), the forearm (719.43), and the hand (719.44); or chronic joint pain as a late effect of fracture of the

      upper extremities (905.2), as a late effect of sprains without mention of injury (905.7), and as late effects of tendon injury (905.8).


  9. LOWER EXTREMITIES


    1. General


      1. Current deformities, disease, or chronic joint pain of pelvic region, thigh (719.45), lower leg (719.46), knee (717.9), ankle and or foot (719.47) that have interfered with function to such a degree as to prevent the individual from following a physically active vocation in civilian life, or that would interfere with walking, running, weight bearing, or the satisfactory completion of training or military duty.


      2. Current leg-length discrepancy resulting in a limp (736.81).


    2. Limitation of Motion. Current active joint ranges of motion less than:


      1. Hip (due to disease (726.5) or injury (905.2))


        1. Flexion to 90 degrees.


        2. No demonstrable flexion contracture.


        3. Extension to 10 degrees (beyond 0 degrees).


        4. Abduction to 45 degrees.


        5. Rotation of 60 degrees (internal and external combined).


      2. Knee (due to disease (726.6) or injury (905.4))


        1. Full extension to 0 degrees.


        2. Flexion to 110 degrees.


      3. Ankle (due to disease (726.7) or injury (905.4) or congenital)


        1. Dorsiflexion to 10 degrees.


        2. Planter flexion to 30 degrees.


        3. Subtalar eversion and inversion totaling 5 degrees.


    3. Foot and Ankle

      1. Current absence of a foot or any portion thereof (896).


      2. Absence of a single lesser toe or any portion thereof that is asymptomatic and does not impair function DOES meet the standard.


      3. Deformity of the toes (735.9) that prevents the proper wearing of military footwear or impairs walking, marching, running, maintaining balance, or jumping.


      4. Symptomatic deformity of the toes (acquired (735) or congenital (755.66)), including but not limited to conditions such as hallux valgus (735.0), hallux varus (735.1), hallux rigidus (735.2), hammer toe(s) (735.4), claw toe(s) (735.5), or overriding toe(s) (735.8).


      5. Clubfoot (754.70) or pes cavus (754.71) that prevents the proper wearing of military footwear or causes symptoms when walking, marching, running, or jumping.


      6. Rigid or symptomatic pes planus (acquired (734) or congenital (754.61)).


      7. Current ingrown toenails (703.0), if infected or symptomatic.


      8. Current or history of recurrent plantar fasciitis (728.71).


      9. Symptomatic neuroma (355.6).


    4. Leg, Knee, Thigh, and Hip


      1. Current loose or foreign body in the knee joint (717.6).



        injury.

      2. History of uncorrected anterior (717.83) or posterior (717.84) cruciate ligament


      3. History of surgical reconstruction of knee ligaments (P81.4) (CPT 27427-27429) DOES meet the standard if 12 months has elapsed since reconstruction, and the knee is asymptomatic and stable.


      4. Recurrent ACL reconstruction (CPT 27427, 27407).


      5. Symptomatic medial (717.82) or lateral (717.42) meniscal injury. The following DOES meet the standard if asymptomatic and released to full and unrestricted activity:


        1. Meniscal repair (CPT 27403), more than 6 months after surgery.


        2. Partial meniscectomy (CPT 27332-27333) more than 3 months after surgery.


      6. Meniscal transplant (CPT 29868).


      7. Symptomatic medial (844.1) and lateral (844.0) collateral ligament instability.


      8. Current or history of congenital dislocation of the hip (754.3), osteochondritis of the hip (Legg-Calve-Perthes Disease) (732.1), or slipped capital femoral epiphysis of the hip (732.2).


      9. Hip dislocation (835) within 2 years preceding examination. Hip dislocation after 2 years DOES meet the standard if asymptomatic and released to full unrestricted activity.


      10. Symptomatic osteochondritis of the tibial tuberosity (Osgood-Schlatter Disease) (732.4) within the past year.


      11. Stress fractures (733.95, V13.52), recurrent or single episode during the past year.


  10. MISCELLANEOUS CONDITIONS OF THE EXTREMITIES


    1. Current or history of chondromalacia (717.7), including but not limited to chronic patello- femoral pain syndrome and retro-patellar pain syndrome (719.46), osteoarthritis (715.3), or traumatic arthritis (716.1).


    2. Current joint dislocation if unreduced, or history of recurrent dislocation, subluxation or instability of the hip (835), elbow (832), ankle (837), or foot.


    3. History of any dislocation, subluxation or instability of the knee (718.86) or shoulder.


    4. Current or history of osteoarthritis (715.3) or traumatic arthritis (716.1) of isolated joints that has interfered with a physically active lifestyle, or that prevents the satisfactory performance of military duty.


    5. Fractures


      1. Current malunion or non-union of any fracture (733.8) (except asymptomatic ulnar styloid process fracture).


      2. Current retained hardware (including plates, pins, rods, wires, or screws) used for fixation that is symptomatic or interferes with proper wearing of equipment or military uniform. Retained hardware is not disqualifying if fractures are healed, ligaments are stable, and there is no pain.


    6. Current orthopedic implants or devices to correct congenital or post-traumatic orthopedic abnormalities (V43).


    7. Current or history of contusion of bone or joint (923, 924), ; an injury of more than a minor nature that shall interfere or prevent performance of military duty, or shall require frequent or prolonged treatment, without fracture, nerve injury, open wound, crush, or dislocation, that occurred in the preceding 6 months and recovery has not been sufficiently completed or rehabilitation resolved.


    8. History of joint replacement or resurfacing of any site (V43.6) (CPT 24363, 27130-27132, 27447).


    9. Current or history of neuromuscular paralysis, weakness, contracture, or atrophy (728) of sufficient degree to interfere with or prevent satisfactory performance of military duty, or requires frequent or prolonged treatment.


    10. Current symptomatic osteochondroma or history of multiple osteocartilaginous exostoses (727.82).


    11. Current osteoporosis (733.0) as demonstrated by a reliable test such as a dual energy x-ray absorptiometry scan (DEXA).


    12. Current osteopenia (733.9) until resolved.


    13. Current osteomyelitis (730.0) or history of recurrent osteomyelitis.


    14. Current or history of osteochondral defect, formerly known as osteochondritis dissecans (732.7).


    15. History of cartilage surgery, including but not limited to cartilage debridement, chondroplasty, microfracture, or cartilage transplant procedure (CPT 20910, 20912, 21230, 21235, 27412, 27415, 29866-29867).


    16. Current or history of any post-traumatic (958.9) or exercise-induced (729.7-79) compartment syndrome.


    17. Current or history of avascular necrosis of any bone.


    18. Current or history of recurrent tendon disorder, including but not limited to tendonitis, tendonopathy, tenosynovitis.


  11. VASCULAR SYSTEM


    1. Current or history of abnormalities of the arteries (447), including but not limited to aneurysms (442), arteriovenous malformations, atherosclerosis (440), or arteritis (such as Kawasaki’s disease) (446).


    2. Current or medically managed hypertension (401). Hypertension is defined as systolic pressure greater than 140 mmHg and or diastolic pressure greater than 90 mmHg confirmed by manual blood pressure cuff averaged over two or more properly measured, seated, blood pressure readings on each of 2 or more consecutive days (isolated, single-day blood pressure elevation is not disqualifying unless confirmed on 2 or more consecutive days).

    3. Current or history of peripheral vascular disease (443.9), including but not limited to diseases such as Raynaud’s Disease (443.0) and vasculidities.


    4. Current or history of venous diseases, including but not limited to recurrent thrombophlebitis (451), thrombophlebitis during the preceding year, or evidence of venous incompetence, such as large or symptomatic varicose veins, edema, or skin ulceration (454).


    5. Current or history of deep venous thrombosis (453.40).


    6. History of operation or endovascular procedure on the arterial or venous systems, including but not limited to vena cava filter, angioplasty, venoplasty, thrombolysis, or stent placement (CPT 34001-37799).


    7. History of Marfan’s Syndrome (759.82).


  12. SKIN AND CELLULAR TISSUES


    1. Current diseases of sebaceous glands including severe and or cystic acne (706), or hidradenitis suppurativa (704-705), if extensive involvement of the neck, scalp, axilla, groin, shoulders, chest, or back is present or shall be aggravated by or interfere with the proper wearing of military equipment. Applicants under treatment with systemic retinoids, including, but not limited to isotretinoin (Accutane®), do not meet the standard until 8 weeks after completion of therapy.


    2. Current or history of atopic dermatitis (691) or eczema (692.9) after the 12th birthday.


      1. Atopic Dermatitis. Active or history of residual or recurrent lesions in characteristic areas (face, neck, antecubital and or popliteal fossae, occasionally wrists and hands).


      2. Non-Specific Dermatitis. Current or history of recurrent or chronic non-specific dermatitis to include contact (692) (irritant or allergic), or dyshidrotic dermatitis (705.81) requiring more than treatment with over the counter medications.


    3. Cysts if:


      1. The current cyst (706.2) (other than pilonidal cyst) is of such a size or location as to interfere with the proper wearing of military equipment.


      2. The current pilonidal cyst (685) is evidenced by the presence of a tumor mass or a discharging sinus, or is a surgically resected pilonidal cyst (CPT 11770-11772) that is symptomatic, unhealed, or less than 6 months post-operative.


    4. Current or history of bullous dermatoses (694), including but not limited to dermatitis herpetiformis, pemphigus, and epidermolysis bullosa, (757.39). Resolved bullous impetigo DOES meet the standard.


    5. Current or chronic lymphedema (457.1).


    6. Current or history of furunculosis or carbuncle (680) if extensive, recurrent, or chronic.


    7. Current or history of severe hyperhidrosis of hands or feet (705.2, 780.8) unless controlled by topical medications.


    8. Current or history of congenital (757) or acquired (216) anomalies of the skin, such as nevi or vascular tumors that interfere with function, or are exposed to constant irritation. History of Dysplastic Nevus Syndrome (232).


    9. Current or history of keloid formation (701.4), including but not limited to pseudofolliculitis and keloidalis nuchae (706.1), if that tendency is marked or interferes with the proper wearing of military equipment.


    10. Current lichen planus (cutaneous and/or oral) (697.0).


    11. Current or history of neurofibromatosis (Von Recklinghausen’s Disease) (237.7).


    12. History of photosensitivity (692.72), including but not limited to any primary sun-sensitive condition, such as polymorphous light eruption or solar urticaria, or any dermatosis aggravated by sunlight, such as lupus erythematosus.


    13. Current or history of psoriasis (696.1).


    14. Current or history of radiodermatitis (692.82).


    15. Current or history of scleroderma (710.1).


    16. Current or history of chronic urticaria lasting longer than 6 weeks or recurrent episodes of urticaria (708.8) within the past 24 months not associated with angioedema, hereditary angioedema (277.6), or maintenance therapy for chronic urticaria, even if not symptomatic.


    17. Current symptomatic plantar wart(s) (078.19).


    18. Current scars (709.2), or any other chronic skin disorder of a degree or nature that requires frequent outpatient treatment or hospitalization, which in the opinion of the certifying authority shall interfere with proper wearing of military clothing or equipment, or which exhibits a tendency to ulcerate or interferes with the satisfactory performance of duty.


    19. Prior burn (949) injury involving 18 percent or more body surface area (including graft sites), or resulting in functional impairment to such a degree, due to scarring, as to interfere with the satisfactory performance of military duty due to decreased range of motion, strength, or agility.

    20. Current localized types of fungus infections (117), interfering with the proper wearing of military equipment or the performance of military duties. For systemic fungal infections, refer to paragraph 24.wq. of this enclosure.


  13. BLOOD AND BLOOD-FORMING TISSUES


    1. Current hereditary or acquired anemia, which has not been corrected with therapy before appointment or induction. ICD-9 codes for diagnosed anemia include hereditary hemolytic anemia (282), sickle cell disease (282.6), acquired hemolytic anemia (283), aplastic anemia (284), or unspecified anemias (285).


    2. Current or history of coagulation defects (286), including but not limited to von Willebrand’s Disease (286.4), idiopathic thrombocytopenia (287), or Henoch-Schönlein Purpura (287.0).


    3. Current or history of diagnosis of any form of chronic or recurrent agranulocytosis and/or leukopenia (288.0).


      1. Spleen


        1. Current splenomegaly (789.2).


        2. History of splenectomy (P41.5) (CPT 38100-38129), except when accomplished for trauma or conditions unrelated to the spleen or for hereditary spherocytosis (282.0).


  14. SYSTEMIC


    1. Current or history of disorders involving the immune mechanism, including immunodeficiencies (279).


    2. Presence of human immunodeficiency virus or serologic evidence of infection (042, V08) or false-positive screening test(s) with ambiguous results on confirmatory immunologic testing.


    3. Current or history of lupus erythematosus (710.0) or mixed connective tissue disease variant (710.9).


    4. Current or history of progressive systemic sclerosis (710.1), including Calcinosis, Raynaud’s phenomenon, Esophogeal dysmotility, sclerodactyly, telangiectasia (CREST) Variant.


    5. Current or history of Reiter’s disease (099.3).


    6. Current or history of rheumatoid arthritis (714.0). g. Current or history of Sjögren’s syndrome (710.2).


      1. Current or history of vasculitis, including but not limited to polyarteritis nodosa and allied conditions (446.0), arteritis (447.6), Behçet’s (136.1), and Wegener’s granulomatosis (446.4).


        image

        ic. Tuberculosis (010)


        1. Current active tuberculosis or substantiated history of active tuberculosis in any form or location, regardless of past treatment, in the previous 2 years.


        2. Current residual physical or mental defects from past tuberculosis that shall prevent the satisfactory performance of duty.


        3. Individuals with a past history of active tuberculosis more than 2 years before appointment, enlistment, or induction meet the standard if they have received a complete course of standard chemotherapy for tuberculosis.


        4. Current or history of untreated latent tuberculosis (positive Purified Protein Derivative with negative chest X-ray) (795.5). Individuals with a tuberculin reaction in accordance with ATS and United States Public Health Service (USPHS) guidelines are eligible for enlistment, induction, and appointment, provided they have received chemoprophylaxis in accordance with ATS and USPHS guidelines. A negative QuantiFERON®-TB Gold (QFT®-G) with a positive tuberculin skin test DOES meet the standard.


      image

      jd. Current untreated syphilis (097). ke. History of anaphylaxis (995.0).

      1. History of anaphylaxis to stinging insects (989.5). A cutaneous only reaction to a stinging insect under the age of 16 DOES meet the standard. Applicants who have been treated for 3-5 years with maintenance venom immunotherapy DO meet the standard.


      2. History of systemic allergic reaction to food or food additives (995.60-995.69). Systemic allergic reaction may be defined as a temporally related, systemic, often multi-system, reaction to a specific food. The presence of a food-specific immunoglobulin E antibody without a correlated clinical history DOES meet the standard.


      3. Oral allergy syndrome.


      4. Hypersensitivity to latex (V15.07).


      5. Exercise-induced anaphylaxis (with or without food).


      6. Idiopathic anaphylaxis (995.0).


      7. Acute, early, or immediate anaphylactic onset.

      8. History of systemic allergic reaction or angioedema.


      image

      lf. Current residual of tropical fevers, including but not limited to fevers, such as malaria

      (084) and various parasitic or protozoan infestations that prevent the satisfactory performance of military duty.


      mg. History of malignant hyperthermia (995.86).


      nh. History of industrial solvent or other chemical intoxication (982) with sequelae.


      oi. History of motion sickness (994.6) resulting in recurrent incapacitating symptoms or of such a severity to require pre-medication in the previous 3 years.


      pj. History of rheumatic fever (390).


      qk. Current or history of muscular dystrophies (359) or myopathies. rl. Current or history of amyloidosis (277.3).

      sm. Current or history of eosinophilic granuloma (277.8) and all other forms of histiocytosis (202.3). Healed eosinophilic granuloma, when occurring as a single localized bony lesion and not associated with soft tissue or other involvement, DOES meet the standard.


      image

      tn. Current or history of polymyositis (710.4) or dermatomyositis complex (710.3) with skin involvement.


      uo. History of rhabdomyolysis (728.88). vp. Current or history of sarcoidosis (135).

      wq. Current systemic fungus infections (117). For localized fungal infections, refer to paragraph 22.t. of this enclosure.


  15. ENDOCRINE AND METABOLIC


    1. Current or history of adrenal dysfunction (255).


    2. Current or history of diabetes mellitus (249.xx, 250.xx). Diabetes mellitus (250) disorders, including:


      1. Current or history of diabetes mellitus (250).


      2. Current or history of pre-diabetes mellitus defined as fasting plasma glucose 110- 125 milligrams per deciliter (mg/dL) and glycosylated hemoglobin greater than 5.7 percent.

      3. History of gestational diabetes mellitus.


      4. Current persistent glycosuria, when associated with impaired glucose tolerance

        (250) or renal tubular defects (271.4).


    3. Current or history of pituitary dysfunction (253), to include history of growth hormone use. Non-functional microadenoma (less than 1cm) DOES meet the standard.


    4. Current or history of gout (274). diabetes insipidus.


    5. Current or history of hyperparathyroidism (252.0) or hypoparathyroidism (252.1).


    6. The following thyroid disorders:


      1. Current goiter (240). Symmetrical simple goiter less than two times normal size with no nodules by ultrasound and normal thyroid function tests DOES meet the standard.


        (2) Thyroid nodule (241.0). A solitary thyroid nodule less than 5mm or less than 3cm with benign histology or cytology DOES meet the standard.


        (23) Current hypothyroidism (244) uncontrolled by medication. Individuals with two normal thyroid stimulating hormone tests within the preceding 6 months DOES meet the standard.


        (34) Current or history of hyperthyroidism (242.9). In remission off of anti-thyroidal medication with normal thyroid function tests for a minimum of 12 months and without evidence of thyroid associated ophthalmopathy DOES meet the standard.


        (4) Current thyroiditis (245).


    7. Current nutritional deficiency diseases, including but not limited to beriberi (265.0), pellagra (265.2), and scurvy (267).


    8. Current persistent glucosuria, when associated with impaired glucose tolerance (250) or renal tubular defects (271.4).


i.h. Current or history of acromegaly, including but not limited to gigantism (253.0), or other disorders of pituitary function (253).


j.i. Dyslipidemia on medical management requiring more than one medication. with low- density lipoprotein (LDL) greater than 200mg/dL or triglycerides greater than 400 mg/dL. Dyslipidemia requiring more than one medication or LDL greater than 190 mg/dL on therapy. All those on medical management must have demonstrated no medication side effects (such as myositis, myalgias, or transaminitis) for a period of 6 months.

    1. Metabolic syndrome beyond the 35th birthday. Metabolic syndrome is defined in accordance with NHLBI and American Heart Association (2005) as any three of the following:


      1. Medically controlled hypertension or elevated blood pressure of greater than 130 mmHg systolic or greater than 85 mmHg diastolic.



        men.

      2. Waist circumference greater than 35 inches for women and greater than 40 inches for


      3. Medically controlled dyslipidemia or triglycerides greater than 150 mg/dl.


      4. Medically controlled dyslipidemia or high-density lipoprotein less than 40 mg/dl in men or less than 50 mg/dl in women.


      5. Fasting glucose greater than 100 mg/dl.


  1. Metabolic bone disease.


    1. Osteopenia, osteoporosis, or low bone mass with history of fragility fracture.


    2. Paget’s disease.


    3. Osteomalacia.


    4. Osteogenesis imperfecta.


  2. Male hypogonadism.


  3. Current or history of islet-cell tumors, nesideoblastosis, or hypoglycemia.


  1. RHEUMATOLOGIC


    1. Current or history of lupus erythematosus (710.0) or mixed connective tissue disease variant (710.9).


    2. Current or history of progressive systemic sclerosis (710.1), including calcinosis, Raynaud’s disease or phenomenon, esophogeal dysmotility, sclerodactyly, telangiectasia (CREST) variant.


    3. Current or history of Reiter’s disease (099.3).


    4. Current or history of rheumatoid arthritis (714.0).


    5. Current or history of Sjögren’s syndrome (710.2).

    6. Current or history of vasculitis, including but not limited to polyarteritis nodosa and allied conditions (446.0), arteritis (447.6), Behçet’s (136.1), and Wegener’s granulomatosis (446.4). Henoch-Schonlein Purpura occurring before the age of 19 with 2 years remission and no sequelae DOES meet the standard.


    7. History of congenital fusion (756.15) involving more than two vertebral bodies or any surgical fusion of spinal vertebrae (P81.0).


    8. Current or history of gout (274).


    9. Current or history of inflammatory myopathy including polymyositis or dermatomyositis.


    10. Current or history of non-inflammatory myopathy to include but not limited to metabolic myopathy such as glycogen storage disease, lipid storage disease, and mitochondrial myopathy.


    11. Current or history of fibromyalgia, myofascial pain, or chronic wide-spread pain.


    12. Current or history of chronic fatigue syndrome.


    13. Current or history of spondyloarthritis including ankylosing spondyloarthritis, psoriatic arthritis, reactive arthritis, or spondyloarthritis associated with inflammatory bowel disease.


    14. Current or history of joint hypermobility syndrome.


    15. Current or history of hereditary connective tissue disorders including but not limited to Marfan’s syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta.


  1. NEUROLOGIC


    1. Current or history of cerebrovascular conditions, including but not limited to subarachnoid

      (430) or intracerebral (431) hemorrhage, vascular stenosis, aneurysm, stroke, transient ischemic attack or arteriovenous malformation (437).


    2. History of congenital or acquired anomalies of the central nervous system (742) or meningocele (741.9).


    3. Current or history of disorders of meninges, including but not limited to cysts (349.2). Asymptomatic incidental arachnoid cyst demonstrated to be stable by neurological imaging over a 6-month or greater time period DO meet the standard.


    4. Current or history of neurodegenerative disorders, including but not limited to those disorders affecting the cerebrum (330), basal ganglia (333), cerebellum (334), spinal cord (335), peripheral nerves (337), or muscles (728).

    5. History of headaches (784.0), including but not limited to migraines (346) and tension headaches (307.81) that:


      1. Are severe enough to disrupt normal activities (such as loss of time from school or work) of more than twice per year in the past 2 years.


      2. Require prescription medications more than twice per year within the last 2 years.


    6. Migraine (346) or migraine variant (346.2) associated with neurological deficits other than scotoma.


    7. Cluster headaches (339.0).


    8. History of head injury (854.0) if associated with:


      1. Post-traumatic seizure(s) occurring more than 30 minutes after injury.


      2. Persistent motor, sensory, vestibular, visual, or any other focal neurological deficit.


      3. Persistent impairment of cognitive function.


      4. Persistent alteration of personality or behavior.


      5. Unconsciousness of 24 hours or more post-injury



        injury.

      6. Amnesia or disorientation of person, place, or time of 7 days duration or longer post-


      7. Cerebral traumatic findings, including but not limited to epidural, subdural, subarachnoid, or intracerebral hematoma on neurological imaging until resolved and 12 months has elapsed since injury.


      8. Associated abscess (326) or meningitis (958.8).



        days.

      9. Cerebrospinal fluid rhinorrhea (349.81) or otorrhea (388.61) persisting more than 7


      10. Penetrating brain injury to include radiographic evidence of retained foreign body or bony fragments secondary to the trauma and/or operative procedure in the brain.


    9. History of moderate head injury (854.03).


      1. Moderate head injuries are defined as:


        1. Unconsciousness of more than 30 minutes but less than 24 hours, or

        2. Amnesia, or disorientation of person, place, or time, alone or in combination, more than 24 hours but less than 7 days duration post-injury, or


        3. Linear skull fracture.


      2. After 12 months post-injury, applicants may be qualified if neurological examination shows no residual dysfunction or complications.


    10. History of mild head injury (854.02).


      1. Mild head injury is defined as:


        1. Unconsciousness of less than 30 minutes post-injury.


        2. Amnesia or disorientation of person, place, or time, alone or in combination, of less than 24 hours post-injury.


      2. After 1 month post-injury, applicants may be qualified if neurological examination shows no residual dysfunction or complications.


    11. History of persistent post-concussive symptoms (310.2) that interfere with normal activities or have duration of more than 1 month. Such symptoms include but are not limited to headache, vomiting, disorientation, spatial disequilibrium, impaired memory, poor mental concentration, shortened attention span, dizziness, or altered sleep patterns.


    12. Current or history of infectious processes of the central nervous system, including but not limited to meningitis (322), encephalitis (323), neurosyphilis (094), or brain abscess (324), if occurring within 1 year before examination, required surgical treatment, or if there are residual neurological defects.


    13. Current or history of paralysis, weakness, lack of coordination, chronic pain (including but not limited to chronic regional pain syndrome or neuralgias), or sensory disturbance or other specified paralytic syndromes (344), including but not limited to Guillain-Barre Syndrome (357.0).


    14. Any seizure occurring beyond the 6th birthday, unless the applicant has been free of seizures for a period of 5 years while taking no medication for seizure control, and has a normal sleep-deprived electroencephalogram and normal neurology evaluation while taking no medications for seizure control.


    15. Chronic nervous system disorders, including but not limited to myasthenia gravis (358.0), multiple sclerosis (340), tremor (333.1), and tic disorders (307.20) (e.g., Tourette’s (307.23)).


    16. Current or history of central nervous system shunts of all kinds (V45.2).

    17. Syncope or atraumatic loss of consciousness. History of recurrent syncope or presyncope (780.2), including blackout, fainting, loss or alteration of level of consciousness (excludes single episode of vasovagal reaction with identified trigger such as venipuncture), unless there has been no recurrence during the preceding 2 years while off all medication for treatment of this condition.


  1. SLEEP DISORDERS


    1. Chronic insomnia (780.5). Within the past year, had difficulty sleeping, or used medications to promote sleep for more than 3 nights per week, over a period of 3 months.


    2. Sleep-related breathing disorders (327). Current diagnosis or treatment of sleep-related breathing disorders, including but not limited to sleep apnea (327.2).


    3. Current or history of narcolepsy, cataplexy (347-347.11), or other hypersomnia disorders (327.13-19).


    4. Circadian rhythm disorders requiring treatment (307.45).


    5. Current or history of parasomnia (327.44, 327.49), including but not limited to sleepwalking, enuresis, or night terrors (307.46), after the age of 15.


    6. Current diagnosis or treatment of sleep-related movement disorders to include restless leg syndrome (327.5).


  1. LEARNING, PSYCHIATRIC, AND BEHAVIORAL


    1. Attention Deficit Hyperactivity Disorder (ADHD) (314) UNLESS the following criteria are met:


      1. The applicant has not required an Individualized Education Program or work accommodations since the age of 14.


      2. There is no history of comorbid mental disorders.


      3. The applicant has never taken more than a single daily dosage of medication or has not been prescribed medication for this condition for more than 24 cumulative months after the age of 14.


      4. During periods off of medication after the age of 14, the applicant has been able to maintain at least a 2.0 grade point average without accommodations.


      5. Documentation from the applicant’s prescribing provider that continued medication is not required for acceptable occupational or work performance.

      6. Applicant is required to enter service and pass Service-specific training periods with no prescribed medication for ADHD.


    2. History of learning disorders (315), including but not limited to dyslexia (315.02), UNLESS applicants demonstrated passing academic and employment performance without utilization of academic and or work accommodations at any time since age 14.


    3. Pervasive developmental disorders (299 series) including Asperger Syndrome, autistic spectrum disorders, and pervasive developmental disorder-not otherwise specified (299.9).


    4. Current or history of disorders with psychotic features such as schizophrenic disorders (295), delusional disorders (297), or other and unspecified psychoses (298).


    5. History of bipolar disorders (296.4-7) and affective psychoses (296.8).


    6. History of depressive disorders, including but not limited to major depression (296), dysthymic disorder (300.4), and cyclothymic disorder requiring outpatient care for longer than 12 months by a physician or other mental health professional (to include V65.40), or any inpatient treatment in a hospital or residential facility.


    7. Depressive disorder not otherwise specified (311), or unspecified mood disorder (296.90), UNLESS:


      1. Outpatient care was not required for longer than 24 months (cumulative) by a physician or other mental health professional (to include V65.40).


      2. The applicant has been stable without treatment for the past 36 continuous months.


      3. The applicant did not require any inpatient treatment in a hospital or residential facility.


    8. History of a single adjustment disorder (309) within the previous 3 months, or recurrent episodes of adjustment disorders.


    9. Current or history of disturbance of conduct (312), impulse control (312.3), oppositional defiant (313.81), other behavior disorders (313), or personality disorder (301).


      1. History (demonstrated by repeated inability to maintain reasonable adjustment in school, with employers or fellow workers, or other social groups), interview, or psychological testing revealing that the degree of immaturity, instability, of personality inadequacy, impulsiveness, or dependency shall likely interfere with adjustment in the Military Services.


      2. Recurrent encounters with law enforcement agencies (excluding minor traffic violations) or antisocial behaviors are tangible evidence of impaired capacity to adapt to military service.

    10. Encopresis (307.7) after 13th birthday.


    11. History of anorexia nervosa (307.1) or bulimia (307.51).


    12. Other eating disorders (307.50; 52-54) including unspecified disorders of eating (307.59) occurring after the 13th birthday.


    13. Any current receptive or expressive language disorder, including but not limited to any speech impediment or stammering and stuttering (307.0) of such a degree as to significantly interfere with production of speech or the ability to repeat commands.


    14. History of suicidal behavior, including gesture(s) or attempt(s) (300.9) or history of self- mutilation or injury used as a way of dealing with life and emotions.


    15. History of obsessive-compulsive disorder (300.3) or post-traumatic stress disorder (309.81).


    16. History of anxiety disorders (300.01), anxiety disorder not otherwise specified (300.00), panic disorder (300.2), agoraphobia (300.21, 300.22), social phobia (300.23), simple phobias (300.29), other acute reactions to stress (308) UNLESS:


      1. The applicant did not require any treatment in an inpatient or residential facility.


      2. Outpatient care was not required for longer than 12 months (cumulative) by a physician or other mental health professional (to include V65.40).


      3. The applicant has not required treatment (including medication) for the past 24 continuous months.


      4. The applicant has been stable without loss of time from normal pursuits for repeated periods even if of brief duration; and without symptoms or behavior of a repeated nature that impaired social, school, or work efficiency for the past 24 continuous months.


    17. Current or history of dissociative, conversion, or factitious disorders (300.1), depersonalization (300.6), hypochondriasis (300.7), somatoform disorders (300.8), or pain disorder related to psychological factors (307.80 and .89).


    18. Current or history of psychosexual conditions (302), including but not limited to transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias.


    19. Current or history of alcohol dependence (303), drug dependence (304), alcohol abuse (305.0), or other drug abuse (305.2 thru 305.9).


    20. Current or history of other mental disorders (all 290-319 not listed) that, in the opinion of the civilian or military medical examiner, shall interfere with or prevent satisfactory performance of military duty.


    21. Prior psychiatric hospitalization for any cause.


2930. TUMORS AND MALIGNANCIES


  1. Current benign tumors (M8000) or conditions that interfere with function, prevent the proper wearing of the uniform or protective equipment, shall require frequent specialized attention, or have a high malignant potential, such as Dysplastic Nevus Syndrome.


  2. Current or history of malignant tumors (V10).


  3. Skin cancer (other than malignant melanoma) that is removed with no residual DOES meet the standard.


  1. MISCELLANEOUS


    1. Current or history of parasitic diseases, if symptomatic or carrier state, including but not limited to filariasis (125), trypanosomiasis (086), schistosomiasis (120), hookworm (uncinariasis) (126.9), or unspecified infectious and parasitic disease (136.9).


    2. Current or history of other disorders, including but not limited to cystic fibrosis (277.0) or porphyria (277.1), that prevent satisfactory performance of duty, or require frequent or prolonged treatment.


    3. Current or history of cold-related disorders, including but not limited to frostbite, chilblain, immersion foot (991), or cold urticaria (708.2).


    4. Current residual effects of cold-related disorders (991.9), including but not limited to paresthesias, easily traumatized skin, cyanotic amputation of any digit, ankylosis, trench foot, or deep-seated ache.


    5. History of angioedema, including hereditary angioedema (277.6).


    6. History of receiving organ or tissue transplantation (V42).


    7. History of pulmonary (415) or systemic embolization (444).


    8. History of untreated acute or chronic metallic poisoning, including but not limited to lead, arsenic, silver (985), beryllium (985.3), or manganese (985.2), or current complications or residual symptoms of such poisoning.


    9. History of heat pyrexia (992.0), heatstroke (992.0), or sunstroke (992.0).


    10. History of three or more episodes of heat exhaustion (992.3).


    11. Current or history of a predisposition to heat injuries (992.0-992.8), including disorders of sweat mechanism (705.0-705.9), combined with a previous serious episode.


    12. Current or history of any unresolved sequelae of heat injury (992.0-992.8), including but not limited to nervous, cardiac, hepatic, or renal systems.


    13. Current or history of any condition that, in the opinion of the medical officer, shall significantly interfere with the successful performance of military duty or training (should use specific ICD code whenever possible, or 796.9).


    14. Any current acute pathological condition, including but not limited to acute communicable diseases, until recovery has occurred without sequelae.

GLOSSARY


PART I. ABBREVIATIONS AND ACRONYMS


ADHD Attention Deficit Hyperactivity Disorder ANSI American National Standards Institute ASD(HA) Assistant Secretary of Defense for Health Affairs ATS American Thoracic Society

AV atrioventricular


CPT Current Procedural Terminology

CREST Calcinosis, Raynaud’s phenomenon, Esophogeal dysmotility, sclerodactyly, telangiectasia


dB decibel

DEP Delayed Entry Program

DoDD Department of Defense Directive

DoDI Department of Defense Instruction

DUSD(MPP) Deputy Under Secretary of Defense for Military Personnel Policy ECG electrocardiograph

GERD Gastro-Esophageal Reflux Disease


HCPCS Healthcare Common Procedure Coding System HHS Department of Health and Human Services


ICD International Classification of Diseases


LASEK laser epithelial keratomileusis

LASIK laser-assisted in situ keratomileusis

LDL low-density lipoprotein

LTBI latent tuberculosis infection


MEDPERS Medical and Personnel Executive Steering Committee mg/dl milligrams per deciliter

mmHg millimeters of mercury


NHLBI National Heart, Lung, and Blood Institute NIH National Institutes of Health


PRK photorefractive keratectomy

PDASD(HA) Principal Deputy Assistant Secretary of Defense for Health Affairs PDES Physical Disability and Evaluation System

PDUSD(P&R) Principal Deputy Under Secretary of Defense for Personnel and Readiness

QFT®-G QuantiFERON®-TB Gold


ROTC Reserve Officer Training Corps


USD(P&R) Under Secretary of Defense for Personnel and Readiness USPHS United States Public Health Service


WPW Wolff-Parkinson-White


PART II. DEFINITIONS


Unless otherwise noted, these terms and their definitions are for the purpose of this Instruction. anemia. A hemoglobin level of less than 13.5 for males and less than 12 for females.

Department of Health and Human Services (HHS). The U.S. Government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.


Military Department. Defined in Joint Publication 1-02 (Reference (j)). Military Service(s). Defined in Reference (j).

NHLBI. An agency within the National Institutes of Health (NIH) that provides global leadership for a research, training, and education program to promote the prevention and treatment of heart, lung, and blood diseases and enhance the health of all individuals so that they can live longer and more fulfilling lives.


NIH. An agency within the HHS that serves as the steward of medical and behavioral research for the Nation. Its mission is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability.


image

QFT®-G. An in vitro laboratory diagnostic test using a whole blood specimen. It is an indirect test for Mycobacterium tuberculosis-complex (i.e., M. tuberculosis, M. bovis, M. africanum, M. microti, M. canetti) infection, whether tuberculosis disease or latent tuberculosis infection (LTBI). It cannot distinguish between tuberculosis disease and LTBI, and is intended for use in conjunction with risk assessment, radiography, and other medical and diagnostic evaluations.