Pernicious Anemia and B12 Deficiency — VA Rating (DC 7722)
Diagnostic Code 7722 · 38 CFR §4.117
What Is It?
Pernicious anemia is an autoimmune condition in which the stomach stops producing intrinsic factor, the protein that lets the small intestine absorb vitamin B12. Vitamin B12 deficiency reaches the same endpoint by other routes: gastrectomy or bariatric surgery, Crohn disease or removal of the ileum, long-term metformin, long-term proton pump inhibitors or H2 blockers, heavy alcohol use, and strict plant-based diets kept up for years. Because B12 is needed for nerve insulation as well as for blood, the condition can present as numbness and tingling in the feet and hands, balance problems in the dark, memory and concentration trouble, and in severe cases spinal cord involvement, alongside the fatigue and breathlessness of anemia. VA rewrote 38 CFR §4.117 effective December 9, 2018, and DC 7722 now turns on treatment and severity at diagnosis rather than on hemoglobin. A 100 percent evaluation applies for initial diagnosis requiring transfusion due to severe anemia, or where there are signs or symptoms of central nervous system impairment such as encephalopathy, myelopathy, or severe peripheral neuropathy requiring parenteral B12 therapy. A 10 percent evaluation applies for requiring continuous treatment with B12 injections, sublingual or high-dose oral tablets, or nasal spray or gel. There is no 30 percent and no 70 percent tier under this code.
Rating Criteria
| Rating | Criteria |
|---|---|
| 100% | For initial diagnosis requiring transfusion due to severe anemia, or if there are signs or symptoms related to central nervous system impairment, such as encephalopathy, myelopathy, or severe peripheral neuropathy, requiring parenteral B12 therapy. Note: the 100 percent evaluation is assigned as of the date of the initial diagnosis requiring transfusion due to severe anemia or parenteral B12 therapy, and continues with a mandatory VA examination six months following hospital discharge or cessation of parenteral B12 therapy. Residual neurologic effects — peripheral neuropathy, myelopathy, dementia — and gastrointestinal residuals are separately evaluated under the appropriate diagnostic codes. |
| 10% | Requiring continuous treatment with Vitamin B12 injections, Vitamin B12 sublingual or high-dose oral tablets, or Vitamin B12 nasal spray or gel. |
| 0% | Where the criteria for a compensable evaluation are not met, 38 CFR §4.31 provides for a 0 percent evaluation. This is still a grant of service connection and preserves the claim for any later increase. |
Evidence Needed
Two clusters of records matter. The first fixes the beginning: the date of initial diagnosis, the hospital discharge summary, transfusion records if you were transfused for severe anemia, and the orders and administration notes for parenteral B12 therapy with start and stop dates. Those dates drive both the 100 percent level and the six-month examination that follows it. The second shows what is ongoing: prescriptions and injection administration records, or documentation of sublingual, high-dose oral, nasal spray, or gel B12, with a refill history that shows the treatment is continuous. Add the workup and the residuals, since those are evaluated separately: intrinsic factor and parietal cell antibody results, methylmalonic acid levels, neurology consults, nerve conduction studies, spinal imaging where myelopathy is suspected, cognitive testing, and any gastrectomy, ileal resection, metformin, or acid-suppression history.
C&P Exam Tips
Know your dates before you walk in: when you were diagnosed, whether you were transfused, whether you received B12 by injection or infusion in a hospital, and when that therapy stopped. Those facts drive the evaluation more than anything you can describe in the room. For ongoing treatment, say exactly what you take and how often, whether it is a shot, a sublingual tablet, a nasal spray, or a gel, because the code lists all of them. Then be specific about nerve and cognitive symptoms, because they are evaluated under their own codes: where the numbness starts and stops, whether you catch a foot on stairs, whether you steady yourself in the dark, what you forget and how often, whether buttons and keys have become harder. Say plainly if symptoms remained after your blood counts normalized, which is common and is exactly what a residuals evaluation is for.
How to File
File on VA Form 21-526EZ with DC 7722. If secondary to a GI condition or medication, identify the primary service-connected condition. Submit B12 levels, CBC results, any neurological testing, and treatment records. A nexus opinion is important if the B12 deficiency is secondary to another condition. If neurological damage is significant, consider also filing under the peripheral neuropathy diagnostic codes for the affected nerves.
Common Mistakes
The first mistake is preparing against the old hemoglobin table, which most published guides still print; those tiers left 38 CFR §4.117 in the December 2018 revision, and a stack of lab values with no diagnosis date, no transfusion record, and no therapy dates gives the rater nothing this code can use. The second is treating the 100 percent evaluation as permanent, then being caught off guard by the mandatory examination six months after discharge or after parenteral therapy ends. The third is letting the neurologic and gastrointestinal residuals go unclaimed, when those are separately evaluated and are often where the lasting disability lives. The fourth is assuming that because injections corrected the blood counts there is nothing left to document, so the continuous treatment itself never makes it into the record.
Frequently Asked Questions
Why is there no 30 or 70 percent under DC 7722?
The code as written has two stated levels: 100 percent for initial diagnosis requiring transfusion due to severe anemia, or for signs or symptoms of central nervous system impairment such as encephalopathy, myelopathy, or severe peripheral neuropathy requiring parenteral B12 therapy, and 10 percent for requiring continuous treatment with B12 in any of its listed forms. Where the criteria for a compensable evaluation are not met, 38 CFR §4.31 provides for a 0 percent evaluation. The intermediate tiers people expect come from the pre-2018 anemia code, which was removed from the schedule.
What happens at the six-month mandatory examination?
The 100 percent evaluation is assigned as of the date of the initial diagnosis requiring transfusion due to severe anemia or parenteral B12 therapy, and it continues with a mandatory VA examination six months following hospital discharge or the cessation of parenteral B12 therapy. That examination looks at where you actually are once the acute phase is over. Treat it as the most important appointment in the claim: have your neurology follow-up, any nerve conduction studies, cognitive testing, and your current treatment record in the file before it happens, and describe what has not recovered.
Are my neuropathy and memory problems rated separately?
Yes. After the period covered by the 100 percent evaluation, residual neurologic effects such as peripheral neuropathy, myelopathy, and dementia are evaluated separately under the appropriate diagnostic codes, as are gastrointestinal residuals. That is why the neurology and cognitive documentation matters so much: the hematologic code accounts for the anemia and its treatment, while the lasting nerve, spinal cord, and digestive effects are rated where they belong. Name each residual in the claim rather than assuming it is carried along by the anemia evaluation.
Do sublingual tablets or nasal spray count, or does it have to be injections?
The 10 percent level names them all. It covers requiring continuous treatment with vitamin B12 injections, sublingual or high-dose oral tablets, or nasal spray or gel. What the criteria ask is whether the treatment is continuous, not which delivery route your provider chose. Make sure the route you use appears in your medication list with a refill history behind it. Veterans who switched from monthly injections to a daily tablet sometimes find the tablet was never added to the chart, which makes ongoing treatment look like it stopped.
My B12 deficiency came from metformin or an acid-reducing medication. Does that help my claim?
It can, as a secondary service connection theory. If the medication was prescribed to treat a service-connected condition and it caused or aggravated the deficiency, the deficiency can be service connected on that basis. You will generally need the prescription history showing long-term use, records showing the deficiency developed during that use, and a medical opinion connecting them. The same reasoning applies to a service-connected gastrectomy, bariatric surgery, or bowel resection that removed the part of the digestive tract where B12 is absorbed.