Citation NR: 9606598 Decision Date: 03/13/96 Archive Date: 03/16/96 DOCKET NO. 94-10 470 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased disability rating for Graves’ disease, manifested by proptosis and diplopia, currently evaluated as 60 percent disabling. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Theresa M. Catino, Associate Counsel INTRODUCTION The veteran served on active military duty from February 1985 to May 1992. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that the regional office (RO) committed error in denying the claim of entitlement to a disability rating greater than 60 percent for Graves’ disease. The veteran asserts that this service-connected disability is more severely disabling than currently evaluated. In particular, she maintains that she should receive separate disability evaluations for her diplopia and her Graves’ disease and that her Graves’ disease should be rated under the appropriate diagnostic code for hypothyroidism rather than the code for hyperthyroidism. DECISION OF THE BOARD The Board of Veterans’ Appeals (Board), in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim of entitlement to a disability evaluation greater than 60 percent for Graves’ disease, manifested by proptosis and diplopia. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim has been obtained insofar as possible. 2. The veteran’s Graves’ disease, which is manifested by diplopia and proptosis of both eyes, some occasional enlargement of her thyroid, and the need for medication, but by essentially normal thyroid hormone (T4 and T3) levels, normal cardiovascular and digestive systems, and no muscular weakness or tachycardia, is productive of no more than severe impairment. 3. The veteran’s diplopia is located in the central 20 degrees of the visual field of each eye. 4. The appropriate diagnostic code which evaluates the nature and extent of the veteran’s Graves’ disease includes consideration of the visual abnormalities resulting from this disorder. CONCLUSION OF LAW A disability rating greater than 60 percent for Graves’ disease, manifested by proptosis and diplopia, is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.14, 4.84, 4.119, Codes 6074, 6090, 7900, 7903 and Table V (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (1995). In a December 1992 rating decision, the RO granted service connection for Graves’ disease, manifested by proptosis and diplopia. The service medical records indicated that Graves’ disease was diagnosed and that the onset of this disorder was dated in July 1991. She underwent numerous treatment sessions for this disorder. According to the March 1992 report of the Medical Evaluation Board Proceedings, the diagnoses of Euthyroid Graves’ disease and thyroid ophthalmopathy secondary to the Graves’ disease, manifested by proptosis and constant diplopia, were made. The report of the Physical Evaluation Board Proceedings, which was dated in the following month, noted that the veteran’s Graves’ disease, which was manifested by proptosis and diplopia, was mild. The only post-service medical record contained in the claims folder at the time of the December 1992 rating decision is the report of the July 1992 VA examination. This evaluation resulted in the diagnosis of Euthyroid Graves’ disease with proptosis and diplopia. Based on this evidence, the RO, in the December 1992 rating decision, assigned a 30 percent disability evaluation for Graves’ disease, manifested by proptosis and diplopia, effective from May 1992. Subsequently, in an April 1994 rating decision, the RO allowed a 60 percent evaluation for this service-connected disorder, effective from May 1992. Disability evaluations are administered under the Schedule for Rating Disabilities which is found in 38 C.F.R. Part 4 (1995) and is designed to compensate a veteran for the average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 1991). Separate diagnostic codes identify the various disabilities. Id. Although the evaluation of a service-connected disability requires a review of the veteran’s medical history with regard to that disorder, the primary concern in a claim for an increased evaluation for a service-connected disability is the present level of disability. The United States Court of Veterans Appeals (Court) has held that, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet.App. 55, 58 (1994). With these regulations and this Court decision in mind, the Board will address the issue of whether an evaluation greater than 60 percent can be assigned for the veteran’s service-connected Graves’ disease. At the July 1992 VA general medical examination, the veteran complained of visual difficulty. This evaluation demonstrated normal cardiovascular and digestive systems. No muscular weakness or tachycardia was noted. Her thyroid was not palpable. The diagnosis of euthyroid Graves’ disease with proptosis and diplopia, was made, and additional testing, including a thyroid profile and an eye consult, was recommended. A visual examination demonstrated diplopia in the central field to 20 degrees. The examiner described the diplopia as intermittent peripherally and correctable by lenses or prisms. Moreover, this evaluation also showed noticeable proptosis of both eyes as well as normal eyegrounds and anterior segment. The diagnosis of diplopia in primary gaze with proptosis of both eyes was made. Corrected visual acuity was 20/30 in each eye. According to an August 1992 report of laboratory work completed in July 1992, the veteran’s thyroid-stimulating hormone (TSH) was 6.1 uIU/mL, which was considered to be abnormal high with the normal range of .6 uIU/mL to 4.6 uIU/mL. In addition, the veteran’s T3 uptake was 25.8%, which was within the normal range of 25% to 37%. His T4 level was 5.9 ug/dL, which was within the normal range of 4.5 to 12.5. Thereafter, the veteran underwent several outpatient treatment sessions at which times her Graves’ disease and thyroid condition were evaluated. An August 1993 VA outpatient treatment record indicated that the veteran had a history of euthyroid Graves’ disease with ophthalmous. The plan included a thyroid profile, appointments at the Ophthalmology and Women’s Clinics, and instructions to return to the outpatient clinic in six months for follow-up. Subsequently, in October 1993, when the veteran went to the local VA Women’s Clinic for a pap smear, her thyroid was found to be two times the normal size. The examiner cited laboratory reports which showed a T4 level of 4.0 ug/dL and a TSH level of 57.2 uIU/mL. An assessment of hypothyroidism was given. According to a January 1994 outpatient treatment record, the veteran reported for follow-up treatment for hypothyroidism. Observation showed a T4 level of 9.3 ug/dL, a TSH level of 1.5 uIU/mL, and medication for this condition. The assessment of euthyroid on replacement was given. The plan included continuation of thyroid replacement and instructions to return to the clinic in five months for follow-up. A February 1994 report noted the results of the July 1992 laboratory work. In addition, this record indicated that the veteran’s T4 level was 4.0 ug/dL in August 1993, 9.3 ug/dL in December 1993, and 8.9 ug/dL in February 1994. The laboratory report also noted that the normal range was 4.5 ug/dL to 12.5 ug/dL and that the veteran’s T4 levels were all normal, except for the August 1993 reading, which was abnormally low. Furthermore, this record cited the veteran’s T3 uptake as 25.6% in August 1993, 32.8% in December 1993, and 30.9% in February 1994. All of the veteran’s T3 uptake readings were with the reference range of 25% to 37% and were, therefore, considered to be normal. This laboratory report also showed TSH levels of 57.2 uIU/mL in August 1993, 1.5 uIU/mL in December 1993, and 3.9 uIU/mL in February 1994. These readings were normal (within the reference range of .6 uIU/mL to 4.6 uIU/mL), except for the August 1993 level, which was abnormally high. An outpatient treatment report dated one week after this laboratory record noted that the veteran had come for follow-up treatment for hypothyroidism. Observations showed normal T4 and TSH levels. The assessment was euthyroid on replacement. The plan included instructions to continue medication and to return to the clinic in six months with a preclinic thyroid profile. In a statement dated in March 1994, the veteran reported that she continues to take medication, including a tablet as well as eye drops. Currently, the veteran is evaluated for her Graves’ disease under Diagnostic Code 7900, which rates impairment resulting from hyperthyroidism. In the substantive appeal, which was received at the RO in December 1993, the veteran contended that her hyperthyroidism has turned into hypothyroidism and that, therefore, her Graves’ disease should be evaluated under Diagnostic Code 7903, which rates impairment caused by hypothyroidism. The Board acknowledges that an October 1993 outpatient treatment record provided the assessment of hypothyroidism. Significantly, however, the most recent medical reports, dated in January and February 1994, confirm the assessment of euthyroidism, which was originally diagnosed during the veteran’s active military duty. Moreover, although slight fluctuations in the level of the veteran’s thyroid hormones have been shown on recent medical reports, her service-connected disability remains Graves’ disease, or hyperthyroidism. From July 1992 to February 1994, her levels of circulating thyroid hormones were only low on one occasion, and that was in August 1993. Consequently, there is no basis for rating her service-connected disability under Code 7903 for hypothyroidism. The Board stresses that the veteran’s service-connected disability is Graves’ disease and that the relevant question concerning the current appeal is whether the nature and extent of this disorder warrants an evaluation greater than the current 60 percent rating. In this regard, the Board notes that, pursuant to Code 7900, severe hyperthyroidism, manifested by marked emotional instability, fatigability, tachycardia and increased pulse pressure or blood pressure, and increased levels of circulating thyroid hormones (T4 and/or T3, by specific assays), warrants the assignment of a 60 percent rating. Evidence of pronounced hyperthyroidism with persistent symptoms of thyroid enlargement, severe tachycardia, increased levels of circulating thyroid hormones (T4 and/or T3 by specific assay), marked nervousness, cardiovascular or gastrointestinal symptoms, muscular weakness, and loss of weight or evidence of post-operative pronounced hyperthyroidism with poor results will result in the assignment of a 100 percent disability rating. 38 C.F.R. § 4.119, Code 7900 (1995). According to the evidence received during the current appeal, the veteran takes medication for her Graves’ disease. In addition, diplopia and proptosis of both eyes has been shown, and her thyroid was found to be enlarged at the October 1993 outpatient treatment session. However, the reports of the post-service VA examination as well as the outpatient treatment sessions (including laboratory work) show that she has had predominantly normal thyroid hormone (T4 and T3) levels. Only an August 1993 T3 level was abnormally low. Moreover, her cardiovascular and digestive systems are normal, and no muscular weakness or tachycardia has been shown, nor has any weight loss been attributed to Graves’ disease. Clearly, the criteria necessary for a 100 percent rating for the veteran’s Graves’ disease have not been satisfied. All of the criteria for a 60 percent evaluation have not been met, in that marked emotional instability, fatigability and increased levels of circulationg thyroid hormones have not been shown. Any of the 100 percent criteria that have been shown have not been persistent. The symptomatology more nearly approximates a 60 percent evaluation. Consequently, a total schedular evaluation under Diagnostic Code 7900 cannot be awarded. 38 C.F.R. §§ 4.7, 4.119, Code 7900 (1995). Moreover, throughout the current appeal, the veteran has asserted that her eye problems, and in particular her diplopia, should be rated separately from her Graves’ disease. Significantly, however, review of Code 7900, the appropriate diagnostic code for the veteran’s Graves’ disease, shows that this rating criteria considers any ophthalmology abnormality associated with the disorder. A note following Code 7900 provides that, if only ophthalmopathy exists, the disability will be rated under impairment of field vision diagnostic code 6080, diplopia diagnostic code 6090, or central visual acuity diagnostic codes 6061-6079. 38 C.F.R. § 4.119, Note 2 following Code 7900 (1995). Because Code 7900 includes consideration of ophthalmology abnormalities related to the hyperthyroidism, the veteran’s ophthalmology symptoms cannot be rated separately from the symptoms associated with her Graves’ disease. The regulations specifically prohibit the use of the evaluation of the same manifestation under different diagnoses. 38 C.F.R. § 4.14 (1995). Consequently, the veteran’s Graves’ disease cannot be evaluated under both Diagnostic Code 7900 for hyperthyroidism and Diagnostic Code 6090 for diplopia. She can receive a rating under only one of these Codes. As the Board has already discussed, she is not entitled to a disability evaluation greater than 60 percent for her Graves’ disease under Code 7900. Moreover, the results of the July 1992 VA ophthalmology examination failed to demonstrate that her diplopia is so severe as to warrant a disability rating greater than 60 percent. According to the report of this evaluation, the veteran’s diplopia was located in the central field to 20 degrees. Best corrected vision was 20/30 in both eyes. The examiner diagnosed diplopia in primary gaze with proptosis of both eyes was made. Diplopia in the central field to 20 degrees represents an equivalent visual acuity of 5/200. 38 C.F.R. § 4.84, Code 6090 (1995). A note following this Code provides that the diplopia ratings will be applied to only one eye. In addition, these ratings will not be applied for both diplopia and decreased visual acuity or field of vision in the same eye. When diplopia is present and there is also ratable impairment of visual acuity or field of vision of both eyes, the diplopia ratings will be applied to the poorer eye while the better eye will be evaluated according to the best corrected visual acuity or visual field. 38 C.F.R. § 4.84, Note 2 following Code 6090 (1995). Therefore, in evaluating the veteran’s diplopia, the Board must consider the visual acuity in one eye to be 5/200 and the best corrected vision in the other eye to be 20/30. These visual acuities correspond to an evaluation of 30 percent. See 38 C.F.R. § 4.84, Table V and Code 6074 (1995). The Board notes that the best corrected vision in the veteran’s eye of 20/30 is rated as 20/40. See 38 C.F.R. § 4.83 (1995). Furthermore, the veteran’s diplopia is shown to be intermittent and correctable, and is not considered a disability. 38 C.F.R. § 4.77 (1995). Therefore, it would not be rated. Clearly, the veteran is not entitled to a disability evaluation greater than 60 percent for her Graves’ disease under the appropriate ophthalmology codes. Moreover, in reaching a determination in this case, the Board has also considered other provisions of 38 C.F.R. Parts 3 and 4 as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). For example, the possibility of an extraschedular evaluation has been considered. However, the Board finds that the present case does not present an exceptional or unusual disability picture. Thus, an increased rating on an extraschedular basis under 38 C.F.R. § 3.321 is not warranted. ORDER The claim for an increased disability evaluation for Graves’ disease, manifested by proptosis and diplopia, is denied. WILLIAM J. REDDY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -