Citation Nr: 0531446 Decision Date: 11/21/05 Archive Date: 11/30/05 DOCKET NO. 95-37 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for fibromyalgia. 2. Entitlement to an increased rating for thyroidectomy with hypoparathyroidism and scar, now rated 10 percent disabling. 3. Entitlement to service connection for a gynecological condition resulting in total hysterectomy and bilateral salpingo-oophorectomy. 4. Whether new and material evidence has been received to reopen a claim for service connection for scars of the abdomen and thyroid areas, and if so, whether service connection is warranted. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Panayotis Lambrakopoulos, Counsel INTRODUCTION The veteran served on active duty from January 1975 to August 1985. This appeal comes before the Board of Veterans' Appeals (Board) from a November 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, that denied claims for service connection for fibromyalgia as secondary to the service- connected thyroid disability and for an increased rating, greater than 10 percent, for the thyroid disability (status postoperative thyroidectomy with surgical hypoparathyroidism and hypothyroidism with asymptomatic surgical scar). The Board remanded these claims in December 2001. The appeal also arises from a March 2003 RO decision that denied a claim for service connection for a gynecological condition resulting in total abdominal hysterectomy with salpingo-oophorectomy; and an application to reopen a claim for service connection for keloid scars from abdominal surgery and thyroid surgery. The veteran testified before the Board in November 2004 and May 2005. (She had also testified before a Member of the Board in July 2001, but that Member is no longer with the Board.) The claim for service connection for fibromyalgia is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. All required notices and assistance to the appellant have been provided, and all evidence needed for disposition of the claims has been obtained. 2. A gynecological condition resulting in total hysterectomy and bilateral salpingo-oophorectomy is related by competent medical evidence to findings in service. 3. Hypothyroidism requires continuous medication for control, and it is manifested by symptoms of fatigability, muscular weakness, cold intolerance, and sleepiness. 4. Hypoparathyroidism requires continuous medication for control, and it is manifested by muscular spasms, numbness and tingling of the arms, legs, and circumoral areas. 5. A January 1986 RO decision that denied service connection for keloid scars is final. 6. Since January 1986, new and material evidence has been submitted that is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim that is sought to be reopened, which raises a reasonable possibility of substantiating the claim. 7. The veteran currently has scars in her thyroid and abdomen areas that are related to an in-service thyroidectomy and an in-service appendectomy and small bowel resection. CONCLUSIONS OF LAW 1. A gynecological condition resulting in total hysterectomy and bilateral salpingo-oophorectomy was incurred in active service. 38 U.S.C.A. § 1130 (West 2002); 38 C.F.R. § 3.303 (2005). 2. The criteria for an increase in a 10 percent rating for hypothyroidism are not met. 38 C.F.R. § 4.119, Diagnostic Code (DC) 7903 (2005). 3. The criteria for a 10 percent rating for hypoparathyroidism are met. 38 C.F.R. § 4.119, Diagnostic Code (DC) 7905 (2005). 4. The claim for service connection for scars of the abdomen and thyroid areas is reopened. 38 U.S.C.A. §§ 1130, 5108 (West 2002); 38 C.F.R. §§ 3.303, 3.156 (2005). 5. Scars of the abdomen and thyroid areas were incurred in active service. 38 U.S.C.A. § 1130 (West 2002); 38 C.F.R. § 3.303 (2005). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West Supp. 2005); 38 C.F.R. § 3.159(b)(1) (2005). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim, or something to the effect that the claimant should "give us everything you've got pertaining to your claim(s)." Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent correspondence in April 2001 and February 2003; statements of the case in March 2001, April 2001, and April 2004; and supplemental statements of the case in May 2001 and April 2004. These documents discussed specific evidence, the particular legal requirements applicable to the claims, the evidence considered, the pertinent laws and regulations, and the reasons for the decisions. VA made all efforts to notify and to assist the appellant with regard to the evidence obtained, the evidence needed, the responsibilities of the parties in obtaining the evidence, and the general notice of the need for any evidence in the appellant's possession. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of that claim by the RO subsequent to receipt of the required notice. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Thus, VA has satisfied its duty to notify the appellant. In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the veteran of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant evidence. VA has also obtained several examinations. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The Board now turns to the merits of the claims. Service connection claim Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Where there is a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); see also 38 C.F.R. § 3.303(d) (2005). A determination of direct service connection requires (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). The veteran seeks service connection for a gynecological condition resulting in total hysterectomy and other conditions (including menorrhagia, bilateral ovarian cyst, fibroid uterus, and hysterectomy). She states that she was treated in service for pelvic inflammatory disease, heavy bleeding, menstrual cramps, and right ovarian cyst disease and that she subsequently underwent a total hysterectomy with bilateral salpingo-oophorectomy. She also contends that hormonal imbalances, as manifested by her service-connected thyroid disability, can produce dysfunctional uterine bleeding. She was seen for trichomonal vaginitis in June 1981, after reports of vaginal discharge. In October 1981, after complaints of abdominal pain, she was treated for recurrent pelvic inflammatory disease; ovarian mass versus adhesions needed to be ruled out. She had pelvic pain with an assessment of right adnexal thickening. A February 1982 gynecological examination was normal, but in February 1983, she had a right adnexal mass of unknown etiology. She was seen for a question of an ovarian cyst in March 1983. During service, the veteran underwent Caesarean section. Thereafter, she developed small bowel obstruction because of scars and adhesions from the surgery, which resulted in additional surgery (small bowel resection, mainly of the terminal ileum). A June 1994 gynecological examination was within normal limits On VA treatment in March 2002, it was noted that she had a two-year history of recurrent cystitis with episodes about every six weeks. The veteran underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and enterotomy repair in June 2002, after a long history of menorrhagia that had been unresponsive to Lupron therapy and after a sonogram had revealed bilateral ovarian cyst and fibroid uterus. A VA doctor found on VA examination in January 2003 that the veteran was mildly anemic with microcytic hypochromic picture with significant iron deficiency. The doctor opined that there was no doubt that the veteran had developed severe malabsorption secondary to small bowel resection that no doubt worsened her previously diagnosed anemia. The examiner also noted that the veteran reported having first developed heavy menstrual bleeding when she was nine years old, with worsening over the years and the continuing need for iron supplements throughout her active service. According to a March 2003 report from a Dr. Michel E. Rivlin, he reviewed the veteran's health records from 1981 to 1983, which showed the presence of adnexal masses thought to be due either to pelvic inflammatory disease or ovarian cysts. He also noted that these findings were associated with pelvic pain and menstrual cramps. Dr. Rivlin opined that "it is most likely rather than least likely that [the veteran's] gynecological condition, namely menorrhagia, menstrual cramps and ovarian cyst disease, was incurred during this time period [i.e., 1981-83] and that this continued until the surgery of June, 2002." Incidentally, the RO awarded service connection and a 10 percent rating for anemia, microcytic-hypochromic, in a January 2004 rating decision. In January 2004, VA urologic clinic notes indicated that the veteran's urinary symptoms had started after the 2002 hysterectomy. This chronology certainly raises questions as to the gap in time between service and the eventual need for surgical intervention in 2002. However, Dr. Rivlin's March 2003 report is definitive on the matter. The doctor reviewed pertinent medical records. Although Dr. Rivlin did not necessarily address the possible lack of gynecological complaints immediately after the veteran's active service, he is a specialist in obstetrics and gynecology, and his opinion appears to be based firmly on his personal medical expertise and his interpretation of the available evidence. At the very least, the evidence on this claim is in equipoise. Therefore, on consideration of the benefit of the doubt under 38 U.S.C.A. § 5107(b), the Board concludes that service connection is warranted for a gynecological condition resulting in total hysterectomy. Increased rating for thyroidectomy with hypoparathyroidism and scar The veteran contends that she should be awarded separate evaluations for hypothyroidectomy residuals and hypoparathyroidism because they involve different glands and different symptoms. Disability evaluations are determined by application of a rating schedule based, as far as can practicably be determined, on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2005). A service-connected disability is rated based on specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (2005). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2005). The disability must be evaluated from the point of view of the veteran working or seeking work and any reasonable doubt about the extent of the disability must be resolved in the veteran's favor. 38 C.F.R. §§ 4.2, 4.3 (2005). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2005). Since the issue is entitlement to an increased rating, the present level of the disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Under the criteria for hypothyroidism, a 10 percent rating is warranted where there is fatigability, or; where continuous medication is required for control. A 30 percent rating is warranted for hypothyroidism involving fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted where hypothyroidism produces muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted for hypothyroidism involving cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, DC 7903 (2005). Under the criteria for hypoparathyroidism, a 10 percent rating is warranted for hypoparathyroidism where continuous medication is required for control. A 60 percent rating is warranted for marked neuromuscular excitability or paresthesias (of the arms, legs, or circumoral area) plus either cataract or evidence of increased intracranial pressure. A 100 percent rating is warranted for marked neuromuscular excitability (such as convulsions, muscular spasms (tetany), or laryngeal stridor) plus either cataract or evidence of increased intracranial pressure (such as papilledema). 38 C.F.R. § 4.119, DC 7905 (2005). In service, the veteran underwent thyroid surgery for Graves disease; the parathyroid glands were accidentally removed as well. Since then, she has been diagnosed with hypothyroidism and hypoparathyroidism, both of which require continuous medication. VA medical records from the 1990s to the present reflect that the veteran has been on thyroid hormone replacement for many years; she is also receiving large amounts of calcium for hypocalcemia. She also had a history of Graves' disease with peripheral visual defect and "poppy" eyes or proptosis with lid lag. Her hypothyroid disability did not present any problems in 1995, but she was starting to have more intense arthralgias. She also demonstrated hypokalemia, hypocalcemia, and hypomagnesemia. Emotionally, she has reported having anxiety. C5 radiculopathy was suspected in connection with right hand tingling in May 1995. In March 1998, she reported having had circumoral and finger tingling for at least a month; the examiner believed that there was some degree of medical non-compliance with respect to decreased calcium, magnesium, and potassium levels. In July 1998, on endocrinology clinic follow-up, she reported muscle spasms, cramps, aching, soreness, weakness, fatigue, elbow pain, edema on her hands, and throat spasms when drinking water. The assessment was that her symptoms of hypoparathyroidism were worsening. She complained of leg and arm muscle spasms in September 1998. In November 1998, with regard to hypothyroidism, her last thyroid tests had been "OK." On VA thyroid examination in July 1999, the veteran denied fatigability, but she described intolerance to heat and cold and extremely variable weight. Her thyroid was not enlarged. Her pulse was 94, and her blood pressure was 155/72. Exophthalmos of the eyes was not present. Muscle strength was normal. She did not have tremor or myxedema. The diagnoses were hypothyroidism secondary to surgical treatment for Graves disease; and hypoparathyroidism, also secondary to surgical treatment for Graves disease. Her free T4 level was low; her TSH level was very elevated. A July 1999 VA stomach examination diagnosed status post small bowel resection as a consequence of emergency caesarean section in 1984; and chronic diarrhea that was secondary to the primary diagnosis. The chronic diarrhea was certainly disabling and extremely symptomatic. She had an impression of thyroid orbitopathy in July 1999; she was to be monitored closely for changes. By the following month, the condition was stable. According to her treating VA endocrinologist in February 2000, Dr. Jose Subauste, the veteran had developed iatrogenic hypothyroidism and hypoparathyroidism subsequent to her thyroidectomy. The veteran's thyroid replacement had been difficult, most likely because of erratic intestinal absorption. The doctor also felt that her history of obesity, obstructive sleep apnea, and carpal tunnel syndrome could be related to her hypothyroidism. The veteran was hospitalized in June 2000 with generalized malaise, whole body weakness, and fatigue; otherwise, she was symptomatically stable with no acute complaints. She was given intravenous replacement of potassium and other electrolytes. Diagnoses included hypokalemia, hypomagnesemia, hypoparathyroidism, hypothyroidism, obstructive sleep apnea, and degenerative joint disease. It was felt that her previous bowel resection was the cause of her electrolyte disturbances. In March 2000, on VA thyroid examination, it was noted that her Synthroid dosages had been increased gradually and that she was now fairly stable with occasional change of thyroid doses. She still had symptoms such as hair loss, impaired memory, and dry skin. Watery stool was attributed to dumping syndrome. She also had been having disrupted calcium metabolism after the thyroid surgery because of accidental removal of the parathyroid glands. She denied having any symptoms at her larynx or esophagus from any pressure symptoms. She had mild cold intolerance and no constipation. She had added 100 pounds since her thyroid condition diagnosis. Objectively, her neck was normal, without lymphadenopathy or thyromegaly. She had mild proptosis and refractory visual problem. She had general fatigue, but no evidence of myxedema or tremors. Diagnoses were history of Graves disease, treated in the past with radiation therapy and later subtotal thyroidectomy; hypothyroidism, post surgery currently on Synthroid, but her thyroid condition had been somewhat active; and history of calcium metabolic disorder, secondary to excision of parathyroid gland in the past. Endocrinological examination was recommended. On VA examination in June 2000, it was noted that the veteran had had several emergency room admissions because of symptomatic hypocalcemia, necessitating intravenous infusion of calcium and magnesium. The impression was hypoparathyroidism that was causing hypocalcemia and hypomagnesemia with the control of calcium and magnesium levels being made difficult by short bowel syndrome and resulting malabsorption. The veteran also had chronic diarrhea and major malabsorption secondary to small-bowel resection. On VA joints examination in September 2000, the veteran complained of fatigue, weakness, morning stiffness, and swelling, as well as constant total body pain. She denied any fever or weight loss. During objective examination of motion of her various joints, the veteran had subjective mild pain. The diagnosis was fibromyalgia. The examiner stated that the etiology of fibromyalgia was unknown at that time; therefore, the examiner could not comment as to whether fibromyalgia was secondary to hypothyroidism. In February 2001, it was noted that she had lost 30 pounds in the past three months. June 2001 thyroid function test results were abnormal in that they showed low T4 and elevated TSH levels; the veteran had a history of fluctuating lab results. In November 2001, the veteran complained of an episode of tingling in the face and hands. The veteran's complaints on VA examination in April 2002 included occasional choking sensation, diarrhea, spasms in the hands and calf muscles consistent with hypocalcemia, occasional blurred vision, double vision on near gaze, and occasional chest palpitations and pain. Her blood pressure was 189/98. She had diplopia on near fixation of the eyes. Readings showed exophthalmus; she had a divergent squint of the eyes. The examiner diagnosed hypothyroidism with a history of Graves disease and consistent eye changes; the veteran was status post thyroidectomy with resulting hypothyroid. She was on adequate replacement of dose, and she was clinically and chemically euthyroid at present. She also had hypoparathyroidism with hypocalcemia, which was a complication of thyroid surgery. Findings indicated partial hypoparathyroidism. She had occasional symptoms of cramps in the feet and legs, but hypocalcemia of this degree for a long time might lessen the symptoms of hypocalcemia somewhat. On VA examination in January 2003, the veteran complained of numbness and tingling in her hands and feet, which had been present ever since her thyroidectomy and subsequent hypoparathyroid. She also had had persistent low calcium levels since then. She had gained weight. She also had constant diarrhea, most likely due to a small bowel resection. She also felt tired, fatigued, and weak. On examination, her blood pressure was 124/68. She had diplopia on near fixation. Her right eye was 25 millimeters on glutameter inspection; the left eye was 23 millimeters. She had a divergent squint. She had acanthosis of the neck and back. She had a thyroid scar in the neck without palpable masses. There was no lymphadenopathy. Chvostek sign was positive for hypocalcemia. Rate was regular with systolic ejection murmur at the left sternal border. Chest was clear to auscultation. The examiner noted that the veteran had become hypothyroid and hypoparathyroid as a complication of her thyroidectomy. She now had vague complaints of hypothyroid including fatigue and weakness. Her TSH level was elevated, suggesting hypothyroid. The thyroid disease seemed active in the form of hypothyroid with continued Synthroid replacement and continued lab checks for Synthroid dosage adjustments. The hypothyroid was a direct complication of her thyroid surgery, and it was complicated by her small bowel resection. Calcium levels indicated that she still had partial hypoparathyroid. In sum, she had signs and symptoms consistent with hypothyroid and hypoparathyroid. The hypoparathyroid was a direct complication of her thyroidectomy. She had persistent low calcium levels, consistent with hypoparathyroid. This was compounded by her small bowel resection, which had impaired her calcium absorption. March 2003 endocrinology treatment records refer to complaints of weakness, paresthesias, and episodic muscle spasms. On treatment in November 2003, a VA endocrinologist commented that the veteran was having swelling in her neck along with shortness of breath as a result of angioedema secondary to use of Fosinopril. The veteran also described spasm in her calves, although she denied perioral numbness or tingling or any facial muscle fasciculations. Other VA medical records from 2003 describe complaints of chronic pain, which were found to be secondary to degenerative joint disease and myofasciitis. According to a February 2004 VA surgery consultation report, the veteran had been doing well on hormone replacement therapy status post thyroidectomy in 1978 until she developed an upper respiratory illness with some upper cervical lymphadenopathy (ectopic thyroid tissue or palpable mass). It was noted that her TSH level had always been slightly elevated (indicating that the thyroid was not completely suppressed). A March 2004 VA thyroid scan showed a functioning mass of irregular thyroid tissue in the midline superior to what was presumed to be the right and left thyroid lobes. There also were focal areas of both decreased and increased activity within this midline mass. April 2004 progress notes show that the veteran continued having symptoms of hypothyroidism, such as decreased energy, hoarseness, and stiffness, as well as swelling of the left side of her neck, paresthesias, and hypocalcemia; calcium had helped to resolve paresthesias. She also had been having shortness of breath. She restarted thyroid replacement medication. According to an April 2004 VA endocrinologist's note, the veteran had a history of Graves' disease that was status post "total" thyroidectomy more than 25 years ago "resulting in hypothyroidism and hypoparathyroidism." The endocrinologist noted that the veteran was on "large amounts of calcium and vitamin D" every day and that she had intermittent episodes of paresthesias and tetany. A subsequent surgical note indicated that the veteran continued to present with some ectopic thyroid tissue (a mass) in the midline that apparently was causing occasional shortness of breath. Other notes indicate that the veteran had suffered damage to the parathyroid and had been left with hypoparathyroidism and hypocalcemia. Records from 2004 have generally shown the TSH levels to be slightly elevated and the T4 levels to be within normal limits. Her pulse has generally ranged from the low 80s to the mid-90s and even upper 90s. She also exhibited Graves ophthalmopathy. In short, the evidence shows clear, objective manifestations of hypothyroidism and hypoparathyroidism. At the present time, service connection is in effect for both disabilities, but only as a single disability. As noted above, separate criteria and separate ratings apply to hypothyroidism and hypoparathyroidism. The veteran suffers from an in-service thyroidectomy that also resulted in accidental removal of her hypoparathyroid. Treating the two disabilities as one entity neglects the separate rating criteria and the separate symptoms from each disability. The Board therefore awards separate ratings for hypothyroidism and hypoparathyroidism. The remaining issue is the appropriate rating for each of these separate disabilities in the context of the veteran's claim for an increased rating. With respect to her hypothyroidism, continuous medication is required; indeed, the dosages of Synthroid have been adjusted periodically to reflect the hormone levels and symptomatology. Thus, a 10 percent rating, at least, is warranted under 38 C.F.R. § 4.119, DC 7903. Over and above that disability level, she also has fatigability. However, she does not have constipation; in fact, she has generally reported diarrhea and other gastrointestinal problems in connection with a separate gastrointestinal disability. Moreover, there generally has not been mental sluggishness on objective examination, even though she has demonstrated anxiety. Thus, the veteran's hypothyroidism does not satisfy the criteria for a 30 percent rating under DC 7903. The veteran's hypothyroidism has produced muscular weakness, which is one of the criteria for a 60 percent rating for hypothyroidism under DC 7903. However, she does not have mental disturbance. Nor does she have weight gain; in fact, in 2001, she reported a 30-pound weight loss. Moreover, while her hypothyroidism meets several criteria for a 100 percent rating (specifically, reports of cold intolerance, muscular weakness, and sleepiness), she does not meet any of the other prerequisites for a 100 percent rating under DC 7903 (specifically, mental disturbance, cardiovascular involvement, or bradycardia). Indeed, her pulse has generally ranged from the 80s to the 90s. In short, the only criteria that the veteran's hypothyroidism symptomatology fully satisfies under DC 7903 are those for a 10 percent rating. However, as the veteran ably points out, her thyroidectomy did not produce only hypothyroidism; rather, it also produced hypoparathyroidism. Continuous medication is required for control of that disability. The record also shows extensive use of medication, particularly with regard to a calcium metabolic disorder due to parathyroid impairment. This meets the criterion for a 10 percent rating under DC 7905. Beyond this level, the veteran certainly has reported muscle spasms and paresthesias, and she does have visual problems. However, there is no evidence of cataract or increased intracranial pressure. Therefore, her hypoparathyroidism does not qualify for any of the other two ratings listed under DC 7905 (i.e., 60 percent or 100 percent). The Board is sympathetic to the veteran's complaints. Nevertheless, the evaluation of a disability is dependent on a comparison to the criteria in VA's Rating Schedule. In this case, only a 10 percent rating is warranted for hypothyroidism under DC 7903. At the same time, a separate 10 percent rating (which was not previously assigned) is warranted for hypoparathyroidism under DC 7905. Finally, the Board notes that the veteran's thyroidectomy involves a scar. To a degree, the Board discusses the aspect of the scar in the section below that concerns scars of the abdomen and thyroid areas from abdominal and thyroid surgeries. The Board notes that the veteran has also contended that certain gastrointestinal symptoms warrant an increased rating for the thyroid disability. However, the Board notes that service connection is already in effect separately for status postoperative appendectomy, status postoperative laparotomies times two, status postoperative partial small bowel resection secondary to peritoneal adhesions with chronic diarrhea, anemia, malabsorption syndrome and asymptomatic surgical scar; that disability is rated 40 percent disabling. To the extent that the veteran seeks an increased rating for her thyroid disability based on symptoms that are already covered by the separate gastrointestinal disability, the Board finds that symptomatology is already compensated. The Board must avoid pyramiding of benefits and may not duplicate benefits. See 38 C.F.R. § 4.14 (2005). Scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries) In January 1986, the RO denied service connection for keloids from abdominal and thyroid surgery. The veteran did not appeal this decision, which thus became final. See 38 U.S.C.A. § 7105 (West 2002). In August 2002, the veteran sought to reopen a claim for scars, describing the scars as "superficial." New and material evidence is required to reopen a claim that has been denied by a final decision. 38 U.S.C.A. § 5108 (West 2002). "New and material evidence" is evidence that is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim that is sought to be reopened, which raises a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156 (a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The claimant does not have to demonstrate that the new evidence would probably change the outcome of the prior denial. Rather, it is important that there be a complete record upon which the claim can be evaluated, and some new evidence may contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability. Hodge, 155 F.3d at 1363. The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). For purposes of the "new and material" analysis, VA presumes the credibility of the proffered evidence. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). Within this framework, the appellant application to reopen the claim for service connection for keloid scars of the abdomina and thyroid areas (from abdominal and thyroid surgeries) must also be viewed in light of the laws and regulations relating to service connection. At the time of the prior final decision (January 1986), the evidence before VA included the veteran's service medical records and post-service medical records, including an unfavorable VA examination that could not identify any keloid. Since the March 1986 decision, VA has received additional evidence. In August 1998, there is reference to keloid in the abdomen. A July 1999 VA stomach examination noted a well-healed surgical scar from just below the xiphoid to above the pubic symphysis. On VA examination in January 2003, it was noted that the veteran had a U-shaped thyroidectomy scar measuring 4.5 inches in length; it was well-healed, non-tender, and non- adherent. She also had a mid-abdominal scar that was 13 inches long overlying the scar of a previous C-section and previous small-bowel resection; the recent (June 2002) hysterectomy had been performed through the same scarring. This scar was not tender and with large stitch marks; a small area of the scarring was still healing, but there was no discharge. The diagnosis was multiple surgical scars that were asymptomatic. The Board notes that service connection is already in effect for asymptomatic surgical scars in connection with other service-connected disabilities (the thyroid disability and an appendectomy with residuals). The veteran's application to reopen the prior final decision has merit. She is seeking separate service connection for surgical scars. To date, the scars, which have been described as asymptomatic, have been considered part and parcel of the more encompassing service-connected disabilities. However, separate rating criteria and disability evaluations are permissible for scars. Therefore, the Board concludes that there is sufficient new and material evidence to reopen a claim for service connection for scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries). The veteran has presented evidence of the continuing existence of these surgical scars. Technically, the January 1986 final RO decision adjudicated the issue of whether there were any keloid scars from the relevant surgeries. Therefore, the veteran's 2002 claim could also be easily construed as a new claim for service connection for scars. While the distinction raises important procedural and jurisdictional considerations, under either approach, the Board would conclude that the issue squarely before the Board (whether based on a reopened claim or an original claim for service connection) is whether the veteran now has service-connected abdomen and thyroid scars from thyroid and abdominal surgeries. Having reopened the claim, the Board will now address the merits of the claim for service connection for scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries). Ordinarily, the case would be remanded for the RO to consider this issue. However, in light of the Board's decision on this claim, there would be no additional benefit to the veteran. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate unquestioning, blind adherence in face of overwhelming evidence in support of the result in a particular case; such adherence would unnecessarily impose additional burdens on VA with no benefit flowing to the claimant). Nor is there any prejudice to the veteran, since the Board's disposition of this claim is favorable to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The record clearly shows that the veteran underwent several surgeries in service, including a thyroidectomy and an appendectomy and small bowel resection. Both surgeries produced surgical scars. And both sets of scars are still visible on the most recent VA examination. Finally, as the Board noted above, the scars have always been treated by VA as part of a service-connected disability. For the sake of clarity, the Board now concludes that separate service connection is warranted for scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries). Whether a separate disability rating is warranted for either scar is a question not before the Board on appeal and must be determined by the RO in the first instance. ORDER Service connection for a gynecological condition resulting in total hysterectomy and bilateral salpingo-oophorectomy is granted. An increased rating for hypothyroidism is denied. A 10 percent rating for hypoparathyroidism is granted. The application to reopen the claim for service connection for scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries) is granted; and service connection for scars of the abdomen and thyroid areas (from abdominal and thyroid surgeries) is granted. REMAND Additional development is needed with respect to the veteran's claim for service connection for fibromyalgia. Despite several VA examinations and extensive medical evidence, there is still uncertainty as to the proper diagnosis of the veteran's complaints of arthralgias, joint pains, muscle pains, and total body pains. The veteran contends that she first manifested symptoms of fibromyalgia during active service, within one year of and as a result of her April 1978 thyroidectomy. She complained of intense pain and soreness with myalgia in April 1979, while still in service; the diagnosis was arthralgia and myalgia secondary to exercise and metabolic alkalosis. In October 1980, she complained of muscle irritability; the diagnosis was hypocalcemia. According to her treating VA endocrinologist in February 2000, Dr. Jose Subauste, the veteran was complaining of arthralgias, especially in the shoulders, neck, and back. She was being seen in a rheumatology clinic for a diagnosis of fibromyalgia, but Dr. Subauste noted that hypothyroidism could also be associated with rheumatologic complaints. On VA joints examination in September 2000, the veteran complained of fatigue, weakness, morning stiffness, and swelling, as well as constant total body pain. She denied any fever or weight loss. During objective examination of motion of her various joints, the veteran had subjective mild pain. The diagnosis was fibromyalgia. The examiner stated that the etiology of fibromyalgia was unknown at that time; therefore, the examiner could not comment as to whether fibromyalgia was secondary to hypothyroidism. A VA doctor, Robert McMurray, wrote in June 2001 as follows: Regarding the medical opinion of whether her fibromyalgia condition is due to hypothyroidism, medical references [specified at the end of the letter] support the concept that hypothyroidism may have presenting symptoms that are fibromyalgic in nature. Conversely, hypothyroidism is in the differential diagnosis of generalized pain syndromes like fibromyalgia. Finally, approximately 50% of fibromyalgia patients have physical, emotional or mental insults that precipitate the fibromyalgia, hence her surgical intervention and resultant electrolyte abnormalities may have precipitated the syndrome. VA treatment records from 2001 to the present reflect complaints of neck, shoulder, and back pain. A November 2001 impression attributed the chronic pain to fibromyalgia. On treatment for back, neck, and shoulder pain in July and August 2003, the impression was chronic pain secondary to degenerative joint disease and myofasciitis. In January 2004, the impression was chronic pain and possible fibromyalgia after the veteran reported chronic pain around the neck and low back area. VA has obtained an examination and several clarifications or addenda from a VA doctor, Dr. Andrew Kang, with regard to the veteran's fibromyalgia. On the first examination in April 2002, according to the veteran, she had pain in her extremities in the late 1970s, along with a diagnosis of myalgia/arthralgia. She indicated that the symptoms persisted after her thyroid problems were treated. Symptoms included fatigue, stiffness, and depression. There were no swellings or deformities on musculoskeletal examination. She had several trigger points that were characteristic of fibromyalgia. The assessment was fibromyalgia syndrome. In a July 2003 addendum, Dr. Kang noted the veteran's account that she had had fibromyalgia symptoms in service. He therefore concluded that it is at least as likely as not that the currently diagnosed fibromyalgia existed during active service, but it is difficult to prove or disprove this contention. Furthermore, it is difficult to be sure whether or not fibromyalgia is related to the service-connected diagnosis of hyperparathyroidism followed by thyroidectomy resulting in hypoparathyroidism. The etiology of fibromyalgia remains unknown and therefore causal relationship of fibromyalgia to the service- connected diagnosis cannot be definitively established. In April 2004, Dr. Kang again reviewed the record and an April 2002 examination. In the resulting fibromyalgia examination report, he stated that it was "not easy to answer . . . definitively" the question of whether the veteran's fibromyalgia syndrome began during active service. He noted the veteran's account of having first developed fibromyalgia symptoms in service, but he stated that he could not find symptoms sufficient to support a diagnosis of fibromyalgia syndrome in the service medical records. He noted that the veteran had been seen in April 1979 for muscle pains and arthralgias, which were attributed to metabolic alkalosis and exercise. The doctor indicated that one would expect myalgias and arthralgias associated with fibromyalgia to be chronic and recurrent, but that there were no other clinical notes of myalgias or arthralgias in service. He stated that it "is not possible to relate the veteran's fibromyalgia syndrome to her period of active service." He also reiterated from his July 2003 examination report that the etiology of fibromyalgia syndrome remained unknown. He commented that some patients with hypothyroidism could experience symptoms resembling fibromyalgia syndrome, but that these symptoms usually improved with treatment of hypothyroidism. He concluded as follows: Thus, on the basis of the absence of written documentation of her symptoms sufficient to support the diagnosis of fibromyalgia syndrome in her service medical records during her period of her active duty, I am now of the opinion that it is less likely that the veteran's currently diagnosed fibromyalgia syndrome is related to her service in the military. As the veteran has pointed out, Dr. Kang's VA examinations ranged from favorable to unfavorable. This underscores the difficulty in precisely identifying the nature of the veteran's disability. On the one hand, service connection is already in effect for hypothyroidism and hypoparathyroidism. The rating criteria for these disabilities involve possible consideration of symptoms such as muscle cramps and paresthesias. See 38 C.F.R. § 4.119, DCs 7903, 7905. On the other hand, where there is a discrete diagnosis of fibromyalgia syndrome, the rating criteria for fibromyalgia also mention possible consideration of muscle cramps and paresthesias. See 38 C.F.R. § 4.71a, DC 5025 (2005). In approaching this claim, the Board is mindful that pyramiding of benefits is not permissible. See 38 C.F.R. § 4.14. However, it is important to determine the precise nature of the veteran's complaints. While remanding the claim for service connection for fibromyalgia raises the question of whether there is any intertwining with the evaluation of the veteran's service- connected hypothyroidism and hypoparathyroidism, the Board considers remanding the fibromyalgia claim while deciding the increased rating claim to be the better course. There is no prejudice to the veteran in this action. First, this approach ensures a disposition of the veteran's long-pending increased rating claim. Second, the Board has considered all identified symptoms in evaluating the service-connected disabilities since there appears to be significant overlap of symptoms. In other words, the Board has not neglected to consider any symptoms that have been discussed in connection with the service-connected hypothyroidism and hypoparathyroidism. Accordingly, the Board REMANDS this claim for the following actions: 1. Schedule the veteran for an examination to assess the precise nature of her arthralgias and myalgias and to determine whether she currently warrants a diagnosed with fibromyalgia syndrome. Provide the claims folder to the examiner. All diagnostic tests should be conducted at this time. Request that the examiner specifically address the relationship, if any, of the veteran's complaints of arthralgia and myalgias to her service-connected hypothyroidism or hypoparathyroidism or their relationship, if any, to fibromyalgia syndrome. Request that the examiner specifically address whether any fibromyalgia syndrome, if diagnosed on examination, is related to any complaints in service. The examiner should also state whether any fibromyalgia syndrome, if diagnosed, is caused by or aggravated by any service- connected disability (including hypothyroidism or hypoparathyroidism). 2. Then, readjudicate the claim for service connection for fibromyalgia. If the decision remains adverse to the appellant, provide the appellant and the representative with a supplemental statement of the case and the appropriate opportunity for response. Then, return the case to the Board for its review, as appropriate. By this remand, the Board expresses no opinion as to the merits of the case. The appellant has the right to submit additional evidence and argument on the matter the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). The RO must treat this claim expeditiously. Claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims must be handled expeditiously. 38 U.S.C. §§ 5109B, 7112 (West Supp. 2005). ______________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs