Citation Nr: 0008299 Decision Date: 03/28/00 Archive Date: 04/04/00 DOCKET NO. 95-19 620 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a compensable rating for polycystic kidney disease. 2. Entitlement to a compensable rating for residuals of cervical dysplasia. 3. Entitlement to a compensable rating for ovarian cystic disease. 4. Entitlement to a 10 percent rating under 38 C.F.R. § 3.324, based upon multiple, non-compensable service- connected disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Richard Giannecchini, Associate Counsel INTRODUCTION The veteran had active military service from July 1985 to December 1989. A perfected appeal to the Board of Veterans' Appeals (Board) of a particular decision entered by a Department of Veterans Affairs (VA) regional office (RO) consists of a Notice of Disagreement (NOD) in writing received within one year of the decision being appealed and, after a Statement of the Case (SOC) has been furnished, a substantive appeal (VA Form 9) received within 60 days of the issuance of the Statement of the Case or within the remainder of the one-year period following notification of the decision being appealed. The present appeal arises from a September 1993 rating decision, in which the RO service connected the veteran for polycystic kidney disease, residuals of cervical dysplasia, and ovarian cystic disease. The disabilities were determined to be noncompensable, with effective dates from July 1992. The RO also determined that entitlement to a 10 percent rating under 38 C.F.R. § 3.324, based upon multiple, non- compensable service-connected disabilities, was not warranted. The veteran filed an NOD in November 1993, and the RO issued an SOC in April 1995. The veteran filed a substantive appeal in June 1995. In August 1995, the veteran testified before a hearing officer at the VARO in Philadelphia. A Hearing Officer's Decision was issued in February 1996. The veteran's appeal subsequently came before the Board, which, in a June 1998 decision, remanded the appeal to the RO for additional development. Supplemental statements of the case (SSOC) were issued in February and August 1999. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The medical evidence of record reflects that the veteran suffers from multiple cysts in her kidneys, urinary tract infections, and flank pain, and has reported hematuria several times a month; she also has suffered from a ruptured right ovarian cyst, and had a laparoscopic tubal ligation, she has not been found to be hypertensive. 3. Applying the rating criteria in effect prior to October 8, 1994, the veteran's polycystic kidney disease is not manifested by moderate cystitis, with pyuria, or by diurnal and nocturnal frequency. 4. Applying the rating criteria in effect on and after October 8, 1994, the veteran's polycystic kidney disease is not manifested by constant or recurring albumin and granular casts or red blood cells, or by transient or slight edema or hypertension. 5. Applying the rating criteria in effect prior to May 22, 1995, the veteran's residuals of cervical dysplasia are not manifested by moderate disease or injury of the cervix. 6. Applying the rating criteria in effect on and after May 22, 1995, the veteran's residuals of cervical dysplasia do not require continuous treatment. 7. On VA examination in October 1998, the examiner reported that there was no current evidence of ovarian cysts. 8. The veteran is reportedly working 40-45 hours a week as a dental assistant. CONCLUSIONS OF LAW 1. The schedular criteria for a compensable rating for polycystic kidney disease are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Codes 7512, 7533 (1994 and 1999). 2. The schedular criteria for a compensable rating for residuals of cervical dysplasia are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7612 (1994 and 1999). 3. The schedular criteria for a compensable rating for ovarian cystic disease are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7620 (1994 and 1999). 4. The veteran is not entitled to a 10 percent rating for multiple noncompensable service-connected disabilities. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.324 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Basis A review of the record reflects that, in July 1992, the veteran submitted a VA Form 21-526 (Veteran's Application for Compensation or Pension) to the RO, in which she filed, inter alia, claims for service connection for cysts in her kidney, cervical dysplasia, and a right ovarian cyst. Along with her application, the veteran submitted copies of her service medical records, and a medical report from William Miller, M.D., dated in March 1992. The report noted that sonograms and ultrasounds had been taken of the veteran's abdomen and pelvis, respectively. A summary of the diagnostic findings reflected a negative gallbladder, in addition to multiple small bilateral renal cysts and generous bilateral renal length, which Dr Miller noted had raised the possibility of adult polycystic renal disease. Furthermore, there were findings of a cystic left adnexal mass, noted as a probable left ovarian cyst with hemorrhage or debris. No right adnexal abnormalities were identified. In November 1992, the veteran submitted a statement to the RO from Laurence Paul, M.D., dated in September 1992. Dr. Paul reported that an evaluation of the veteran's abdomen continued to show bilateral renal cystic disease and left ovarian cysts. He noted that her blood work had showed normal kidney function. Furthermore, the veteran had been seen in the past year for urinary tract infections, without significant sequelae. In December 1992, the RO received additional medical records from Dr. Paul, dated from December 1991 to October 1992. In particular, a report from Jose Galindo, Jr., M.D., to Dr. Paul, dated in April 1992, noted that Dr. Galindo had treated the veteran for galactorrhea. Dr. Galindo noted the veteran's medical history, and reported that she was quite active, and enjoyed walking, reading, and many other sports activities. A laboratory report, dated later that month, noted normal albumin levels. A treatment record, dated in October 1992, reflected the veteran's complaints of back pain, with no urinary symptoms. She also reported hematuria during menstruation. In September 1993, the veteran submitted a copy of letter from Allstate Insurance Company, dated in June 1992, in which it was noted that she was not eligible for life insurance with the company following its review of her medical records. In a September 1993 rating decision, the RO granted the veteran service connection for polycystic kidney disease, residuals of cervical dysplasia, and ovarian cystic disease. The decision noted that the rating board had been unable to determine the level of the veteran's disabilities because she had failed to report for examination. Therefore, the disabilities were found to be noncompensable. The RO also denied the veteran entitlement to a 10 percent rating under 38 C.F.R. § 3.324. She filed an NOD in November 1993, in which she indicated that she had not received the notification for her VA examination. She also reported that she had planned on becoming a state police officer but her medical condition disqualified her as a candidate. The veteran also indicated that she was no longer able to enjoy some sport activities because of the fear of further damaging her kidneys. In June 1994, the veteran submitted a VA Form 21-4138 (Statement in Support of Claim) to the RO, in which she reported that she had been diagnosed with chronic kidney disease by a VA physician at the VA Medical Center (VAMC) in Brockton, MA. Furthermore, she noted that she had been recently diagnosed with two cysts on her right ovary. In August 1994, the veteran submitted copies of both VA and non-VA medical records, dated from September 1990 to July 1994. In particular, A VAMC Brockton/West Roxbury lab report, dated in February 1994, noted the veteran's albumin levels within normal limits. A VA Brockton /West Roxbury ultrasound report, also dated in February 1994, noted multiple hypoechoic areas in both kidneys, and that some hyperechoic echoes inside the cysts could be secondary to hemorrhage or calcifications. Both ovaries were reported to be normal. An April 1994 VAMC Brockton/West Roxbury treatment record noted that the veteran did not suffer from gross hematuria, and that neither her mother or father had suffered from polycystic kidney disease. In addition, a medical report from D. Leslie Adams, M.D., dated in June 1994, noted that the veteran had a questionable left ovarian cyst. An ultrasound was subsequently performed which revealed two small peripheral cysts on the right ovary and a small amount of free fluid in the cul-de-sac, and multiple small cysts in both kidneys. A June 1994 VAMC Lebanon treatment record noted the veteran's medical history, and reported that she had not suffered from hypertension or gross hematuria, that she had had ovarian cysts which had been drained during laparoscopy procedures, and that she had previously suffered from cervical dysplasia, with her last Papanicolaou (PAP) smear that month. The physician noted that the veteran's conditions appeared stable with no signs of infection. In September 1994, the veteran was medically examined for VA purposes. The examiner noted the veteran's medical history, and reported that there was no family history of polycystic kidney disease or renal disease. The veteran was noted to complained of back pain, and her blood pressure was 104/70. On clinical evaluation, the abdomen was soft without masses. There were no caliculi, nor was there evidence of infection. An echogram/ultrasound revealed increased echotexture throughout both kidneys bilaterally, with non-specific cystic changes in the left kidney and a single cystic lesion in the upper pole. The study's report also noted that there was no conclusive evidence of polycystic kidney disease. The examiner's impression was multiple renal cysts. In an April 1995 rating decision, the RO denied the veteran compensable evaluations for polycystic kidney disease, residuals of cervical dysplasia, ovarian cystic disease, and entitlement to a 10 percent rating under 38 C.F.R. § 3.324. In May 1995, the veteran submitted a statement to the RO, in which she reported that the most recent medical evidence reflected a worsening of her condition. This, she reported, included a cyst on her liver, with enlargement of the organ. The veteran also reported that she suffered from kidney pain frequently, and that it was sometimes difficult for her to pick up her son, who reportedly weighed 25 pounds. In addition to her statement, the veteran submitted additional medical evidence. This included a September 1994 VAMC Lebanon laboratory report which noted that the veteran's hematocrit and hemoglobin were low, but albumin was within normal limits. A VAMC Lebanon CT (computed tomography) scan report, dated in October 1994, revealed multiple tiny cystic lesions in the right and left lobe of the liver and multiple cysts of varying sizes throughout both kidneys with otherwise normal renal function. The examiner noted that, due to the lack of distortion of the pelvocalyceal system and otherwise normal function of both kidneys, polycystic kidney disease was the less likely diagnosis. She also indicated that, in the differential diagnosis, she would consider hepatica and Von Hippel-Lindau Syndrome. Furthermore, a Harrisburg Hospital sonogram report, dated in December 1994, revealed bilateral renal cysts and some associated renal caliculi, without renal enlargement, and no evidence of hydronephrosis or obstruction. In June 1995, the veteran submitted a statement to the RO, in which she reported that her last urine test had shown high protein levels, and that a urine specimen in May 1995 had shown trace amounts of blood. She included with her statement a duplicate copy of a September 1994 VA examination report, and a VAMC Lebanon laboratory report, dated in May 1995, which noted a high protein level. In August 1995, the veteran and her spouse testified before a hearing officer at the VARO in Philadelphia. She reported that the pain associated with her medical condition had increased dramatically since it had first been diagnosed. The veteran testified that she took pain medication, was constantly undergoing tests, and had blood work done every three to six months. She also stated that she was not allowed to participate in any contact sports, that it was painful for her to travel in a car, and that it was difficult for her to pick up her son because the area of her kidneys was painful to touch. In addition, the veteran reported that she had been working at Miller Oral Surgery for six years, and that she had lost a week or more of time over the past year and a half due to her medical condition. She testified that she had been advised not to have any more children, and that she worried that her medical condition would make it impossible for her to continue to work in the future. Furthermore, the veteran's spouse noted that the veteran was exhausted when she returned home after work every day, and that she was in constant pain. In September 1995, the RO received medical records from Harrisburg Hospital, dated in December 1994. These records noted the veteran as having undergone a laparoscopic cholecystectomy which included the removal of her gallbladder. That same month, September 1995, the RO received VAMC Lebanon medical records, dated from February 1994 to August 1995. In particular, a May 1995 record noted the veteran's complaints of flank pain. There was a report of nocturia but no dysuria. On clinical evaluation there was mild right upper quadrant tenderness, without guarding or rigidity. The assessment was hematuria possibly secondary to menstruation. An August 1995 record noted the veteran's complaints of nausea and vomiting, with back pain and burning on urination. The assessment was probable recurrent urinary tract infection. In October 1995, the RO received medical records from G.R. Ehgartner, M.D., dated from December 1991 to August 1995. In particular, an October 1992 treatment record noted no urinary symptoms. A February 1993 Harrisburg Hospital report noted the veteran to have been treated for gastroenteritis. During the course of her hospitalization, she was noted to have had a normal urinalysis. A January 1995 ultrasound examination at the VA outpatient clinic (VAOPC) in Camp Hill revealed bilateral small renal cysts, with no other significant findings. An August 1995 GI (gastrointestinal) series performed by J. Russell Croteau, M.D., was reported essentially unremarkable. An August 1995 laboratory report noted albumin and protein levels within normal limits. Also in August 1995, a treatment record noted her complaints of dizziness, vomiting, diarrhea, and blood in her urine. Thereafter, in August 1998, the RO received VAOPC Camp Hill medical records, dated from August 1995 to February 1998. In particular, an October 1996 treatment record noted the veteran's report that a cyst in her left ovary had ruptured. Her condition was noted as stable. She was reportedly scheduled for an oophorectomy at Harrisburg Hospital. A December 1996 treatment record noted that the veteran's polycystic kidney disease was stable. An April 1997 laboratory report reflected the veteran's albumin and protein levels as normal. An October 1997 treatment record noted that an MRI of the veteran's kidneys had been negative, and she had complained of blood in her urine for two weeks. In October 1998, the veteran was medically examined for VA purposes. The examiner noted the veteran's medical history, and reported that she complained of chronic flank pain. Her last urinary tract infection was noted to have occurred during the summer of 1998, and she had been treated with antibiotics. The veteran reported that she had had no proteinuria, but had noticed hematuria several times a month. She indicated that she had no history of symptomatic kidney stones, although there was a question of possible renal caliculi in her cysts. Furthermore, there was no peripheral edema or evidence of high blood pressure, no current dyspareunia, but occasional menstrual cramps. There had been no abnormal PAP smears since laser surgery which she had undergone in service. The veteran also reported that, in November 1996, she was found to have a ruptured right ovarian cyst. She had a laparoscopic tubal ligation, during which she was treated for a cyst on her right ovary. Since that time, she reported having no dyspareunia or pelvic pain. On clinical evaluation, the veteran's blood pressure was noted as 114/72. Her abdomen was soft, nontender without masses, and without bruit. There was mild flank pain bilaterally on palpation. Her kidneys were not palpable, and there was no peripheral edema. Diagnostic test results revealed normal CBC (complete blood count) and SMA-12 (blood chemistry). Urinalysis was normal without blood or protein. A 24-hour urine collection for proteinuria was negative. Ultrasound of the kidneys showed a left kidney cyst. Ultrasound of the ovaries revealed no cyst in the left ovary, and an unvisualized right cyst. The examiner's diagnosis was polycystic kidney disease, with frequent urinary tract infections, chronic flank pain, no renal dysfunction, and episodes of hematuria by history. Also noted were history of cervical dysplasia, status post laser treatment, with no abnormal PAP smear since the laser treatment; as well as history of ovarian cysts, without current evidence of ovarian cysts, although the cysts could and do recur. In a subsequent January 1999 addendum to the October 1998 VA examination report, the examiner reported that a review of the available laboratory data in the veteran's claims file did not reflect evidence of constant or recurrent albumin with hyaline or granular casts. Furthermore, the examiner noted that there had been one urinalysis with red blood cells, and that this had been on a clinical visit when the veteran was menstruating. Furthermore, the veteran had reported a history of hematuria, but there had been no lab slips documenting the problem. The examiner concluded the veteran's polycystic kidney disease was not manifested by constant or recurrent albumin with hyaline and granular casts, or red blood cells. In June 1999, the RO received medical records from Bruce Gronkiewicz, M.D., dated in August 1997. Dr. Gronkiewicz noted the veteran's complaints of fatigue, weakness, nausea, diarrhea, and flank pain. She reported being concerned that there was something wrong with her kidneys or adrenal glands. Following a clinical evaluation, Dr. Gronkiewicz reported that he doubted the veteran suffered from polycystic kidney disease, given her family history, but that she did probably suffer from multiple renal cysts. He noted that, since the veteran's renal function was good and her urine was free of protein, she should be tested occasionally for proteinuria and hypertension. Furthermore, Dr. Gronkiewicz reported that, given the lack of any pertinent clinical findings reflective of adrenal disease, it did not appear the veteran was suffering from such a disorder. II. Analysis The veteran has submitted well-grounded claims within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). That is, the Board finds that she has submitted claims, which are plausible. This finding is based in part on the veteran's assertion that her service-connected polycystic kidney disease, residuals of cervical dysplasia, and ovarian cystic disease are more severe then previously evaluated. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Board is also satisfied that all relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained, and that no further assistance is required to comply with the duty to assist her as mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7 (1999). 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. See Francisco v. Brown, 7 Vet.App. 55, 58 (1994); 38 C.F.R. §§ 4.1, 4.2 (1999). a. Polycystic Kidney Disease With respect to polycystic kidney disease, the RO has assigned a noncompensable evaluation in accordance with the criteria set forth under 38 C.F.R. § 4.115(a)(b), Diagnostic Code (DC) 7533. During the course of the veteran's appeal, substantive changes were made by regulatory amendment to the schedular criteria for evaluating disabilities of the genitourinary system as set forth in 38 C.F.R. § 4.115. See 59 Fed. Reg. 46,339 (1994). These regulations became effective February 17, 1994, and again effective October 8, 1994. See 38 C.F.R. §§ 4.115a, 4.115b (1999). The veteran's polycystic kidney disease prior to October 8, 1994, was evaluated analogously to chronic cystitis under 38 C.F.R. §§ 4.115a, 4.115b, DC 7512. In this respect, a noncompensable evaluation was warranted where there was evidence of mild cystitis. A 10 percent evaluation was warranted where there was evidence of moderate cystitis, with pyuria as well as diurnal and nocturnal frequency. A 20 percent evaluation was warranted where there was moderately severe cystitis, with diurnal and nocturnal frequency as well as pain and tenesmus. A 40 percent evaluation was warranted where there was severe cystitis, with urination at intervals of one hour or less, or a contracted bladder. A 60 percent evaluation was warranted where incontinence existed, which required constant wearing of an appliance. 38 C.F.R. § 4.115a, 4.115b, DC 7512 (1994). Under the current criteria, in effect on and after October 8, 1994, the veteran's polycystic kidney disease is rated under DC 7533 for cystic diseases of the kidneys. As such, under DC 7533 the veteran's disability is rated as renal dysfunction. In this respect, a noncompensable rating is warranted for renal dysfunction, manifested by albumin and casts with a history of acute nephritis; or, hypertension noncompensable under DC 7101. A 30 percent rating is warranted for constant or recurring albumin and granular casts or red blood cells; or transient or slight edema or hypertension at least 10 percent disabling under DC 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under DC 7101. An 80 percent rating is warranted where there is persistent edema and albuminuria with BUN 40 to 80 mg%; or creatinine 4 to 8 mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for disability requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg%; or creatinine more than 8 mg%; or markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a, 4.115b, DC 7533 (1999). Under 38 C.F.R. § 4.104, DC 7101, a 40 percent rating is warranted if diastolic pressure is predominantly 120 or more. A 20 percent rating is warranted if diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. A 10 percent rating is warranted if diastolic pressure is predominantly 100 or more, or systolic pressure is predominately 160 or more, or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For the purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires that hypertension be evaluated due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. In reviewing the evidence, the Board notes that the veteran has consistently complained of flank pain associated with polycystic kidney disease. Various echograms, sonograms, and CT scans have documented cysts on the veteran's kidneys. However, as noted above, polycystic kidney disease is rated based on renal dysfunction, and the medical evidence of record does not reflect the veteran to be suffering from any current renal dysfunction. In reaching this conclusion, we note that the evidence does not reflect symptoms such as pyuria, frequent urination, tenesmus, acute nephritis, constant or recurring albumin and granular casts or red blood cells, light edema, or hypertension. Therefore, the Board finds the veteran's polycystic kidney disease is appropriately rated as noncompensable under the rating criteria in effect before, and on and after, October 8, 1994. 38 C.F.R. § 4.115, DC 7215 and 7355 (1994 and 1999). b. Cervical Dysplasia and Ovarian Cystic Disease During the course of the veteran's appeal, substantive changes were made by regulatory amendment to the schedular criteria for evaluating gynecological conditions and disorders of the breast. See 60 Fed. Reg. 19,851 (1995). These regulations became effective May 22, 1995. See 38 C.F.R. § 4.116 (1999). With respect to cervical dysplasia, the disability is rated under DC 7612 for disease or injury of the cervix. Under the rating criteria in effect prior to May 22, 1995, a noncompensable rating was assignable for mild symptomatology. A 10 percent evaluation was appropriate for moderate symptomatology. A 30 percent rating was warranted for a severe condition with chronic residual of infections, burns, chemicals, or foreign bodies. 38 C.F.R. § 4.116a, DC 7612 (1994). With respect to the current rating criteria on and after May 22, 1995, disease or injury of the cervix is evaluated based upon the necessity of, or lack of requirement for, continuous treatment. Specifically, a disease or injury of the cervix which does not require continuous treatment warrants a noncompensable disability rating. Symptoms of a disease or injury of the cervix which require continuous treatment will result in the assignment of a 10 percent evaluation. In addition, a 30 percent rating is warranted for symptoms of a disease or injury of the cervix which are not controlled by continuous treatment. 38 C.F.R. § 4.116, DC 7612 (1999). In this instance, since the veteran's cervical dysplasia was diagnosed and treated in service, she has not complained of any residual disability, nor does the medical evidence reflect treatment for any residual disability. The veteran's PAP smears since her surgery have all been reported negative. On VA examination in October 1998, no residual disability was identified, and the examiner noted a history of cervical dysplasia, with the veteran needing continued regular monitoring. Thus, the medical evidence reflects that the veteran does not currently have any cervical pathology and is properly evaluated at the noncompensable level under both the old and current rating criteria. 38 C.F.R. §§ 4.116, 4.116a, DC 7612 (1994 and 1999). With respect to ovarian cystic disease, the Board notes that no substantive changes were made to DC 7620 with the change in regulations for gynecological conditions and disorders of the breast, noted above. We are also cognizant that there is not a listed disability rating for ovarian cystic disease, and the RO has attempted to rate the disease analogously under a closely related disability. As such, the RO has rated ovarian cystic disease under DC 7620, for atrophy of both ovaries. Under this Code, atrophy of both ovaries warrants a 20 percent disability rating. In reviewing 38 C.F.R., Part 4, the Board can find no other diagnostic code that would be more appropriate in rating the veteran's disability. In reviewing the evidence, we note that the veteran suffered a rupture of a right ovarian cyst, and in November 1996 had the cyst removed during a tubal ligation. On VA examination in October 1998, the examiner noted that the veteran currently did not suffer from ovarian cysts, but that they could manifest and recur in the future. Thus, given that the medical evidence does not reflect that the veteran's ovaries have atrophied or are otherwise damaged, the Board finds that she is properly evaluated at the noncompensable level for her ovarian cystic disease. 38 C.F.R. § 4.116, DC 7620 (1994 and 1999). We also recognize that the Court of Appeals for Veterans Claims has addressed the distinction between a veteran's dissatisfaction with the initial rating assigned following a grant of entitlement to compensation, and a later claim for an increased rating. See Fenderson v. West, 12 Vet.App. 119, 126 (1999). The Court noted that the rule from Francisco v. Brown, supra, as to the primary importance of the present level of disability, was not necessarily applicable to the assignment of an initial rating following an original award of service connection for that disability. Rather, the Court held that, at the time of an initial rating, separate ratings can be assigned for separate periods of time based upon the facts found - a practice known as assigning "staged" ratings. In view of the holding in Fenderson, the Board has considered whether the veteran was entitled to a "staged" rating for any of her service-connected disabilities, as the Court indicated can be done in this type of case. As noted above, she submitted her claim for polycystic kidney disease, residuals of cervical dysplasia, and ovarian cystic disease in July 1992. Upon reviewing the longitudinal record in this case, we find that, at no time since the filing of the claims for service connection, have her disabilities been more disabling than as currently rated under the present decision. c. 10 Percent Rating under 38 C.F.R. § 3.324 The veteran has been granted service connection for polycystic kidney disease, residuals of cervical dysplasia, and ovarian cystic disease. Each of these disabilities has been evaluated as noncompensable. It is essentially maintained that the disabilities, although noncompensable in nature, interfere with employability and therefore warrant the assignment of 10 percent evaluation in accordance with the provisions of 38 C.F.R. § 3.324. Whenever a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of a compensable degree under VA's Schedule for Rating Disabilities, the rating agency is authorized to appoint a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. We note the veteran has complained of pain and fatigue associated with polycystic kidney disease. During her personal hearing in August 1995, her husband reported that the veteran came home from work exhausted, and was in constant pain. She is currently not suffering from any residuals associated with cervical dysplasia or ovarian cystic disease. As noted on VA examination in October 1998, the veteran reported that she had not experienced any pelvic pain since her tubal ligation in November 1996. She currently works 40-45 hours a week as a dental assistant. Upon review of the medical history and records, we find no evidence that her service-connected disabilities are productive of impairment which would interfere with normal employability. In this regard, we note that the veteran continues to work, but has reported concern about working in the future if her disease progresses and becomes more severe. During her VA examination in October 1998, there were no complaints or findings that her disabilities interfered with her employment. It has not been demonstrated that the veteran's service- connected disabilities impact upon her ability to function generally in the employment setting, based upon the medical evidence of record. The Board concludes that a 10 percent rating in accordance with the provisions of 38 C.F.R. § 3.324 is not warranted. In tht event her disorders should worsen in terms of the particular applicable rating schedule provisions, or in their impact upon her overall occupational efficiency, she is free to file a claim for an increased rating. ORDER 1. Entitlement to a compensable rating for polycystic kidney disease is denied. 2. Entitlement to a compensable rating for cervical dysplasia is denied. 3. Entitlement to a compensable rating for ovarian cystic disease is denied. 4. Entitlement to a 10 percent rating under 38 C.F.R. § 3.324, based on multiple, non-compensable service- connected disabilities, is denied. ANDREW J. MULLEN Member, Board of Veterans' Appeals