Citation Nr: 1328309 Decision Date: 09/05/13 Archive Date: 09/16/13 DOCKET NO. 11-11 652 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to a compensable evaluation for varicose veins in both lower extremities. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1953 to October 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office in Winston-Salem, North Carolina (RO). In pertinent part of that rating decision, the RO denied an increased evaluation for varicose veins disability. The Veteran submitted additional evidence and his claim was reconsidered, but his noncompensable evaluation continued in a January 2010 rating decision. The Veteran appealed. In June 2013, the Veteran testified during a videoconference before the undersigned Acting Veterans Law Judge. A copy of the hearing transcript has been associated with the claims folder. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The medical evidence of record shows that the Veteran suffers from chronic edema in his lower extremities. Pertinently, the criteria for compensable evaluations for disability due to varicose veins under 38 C.F.R. § 4.104, Diagnostic Code 7120, involves manifestations of edema. In this regard, varicose veins warrant a 10 percent evaluation when manifested by intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery; a 20 percent evaluation is warranted for persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema; a 40 percent rating is warranted for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; a 60 percent rating is warranted for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration; a 100 percent rating is warranted for massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104, Diagnostic Code 7120. However, it is unclear whether what degree, if any, the chronic edema symptomatology in the Veteran's lower extremities are attributable to his service-connected varicose veins as opposed to nonservice-connected disabilities, including chronic heart failure, chronic kidney disease, peripheral vascular disease, and/or diabetic neuropathy. See August 2009 private medical treatment record from Blue Ridge Cardiology and Internal Medicine (attributes symptoms of telangiectasais, venous stasis and edema to his varicose veins); in contrast, see April 2011 VA treatment record (identifies edema in lower extremities as multifactorial, secondary to chronic heart failure, venous insufficiency, amlopidpine, deep vein thrombosis, and nephritic syndrome). When a claimant has both service- connected and nonservice-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Therefore, a new VA examination is necessary to clarify whether any symptomatology may be attributed to his service-connected varicose veins disability as opposed to his nonservice- connected disorders. Moreover, the medical and lay evidence of record shows that the edema in the Veteran's lower extremities have worsened since his last VA examination in December 2009. Given the possible etiology of the edema to the Veteran's varicose veins, as well as the passage of over three since the last VA examination, a new VA examination is needed to evaluate the severity of the Veteran's varicose veins. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide the names and addresses of any and all health care providers who have provided treatment for his service- connected disability. After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. 2. Obtain all outstanding VA treatment records and reports generated since 2012. Efforts to obtain these records must be associated with the claims file and requests for these records must continue until the agency of original jurisdiction (AOJ) determines that the records sought do not exist or that further efforts to obtain those records would be futile. 3. Schedule the Veteran for a VA veins and arteries examination to address the current severity of his service- connected varicose veins in his lower extremities. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. Any and all studies, tests and evaluations determined to be clinically necessary should be performed. The examiner should identify all manifestations of the Veteran's varicose veins in his left and right lower extremities and specifically comment on whether the edema in his lower extremities may be attributed to the Veteran's service-connected disability. To the extent possible, the examiner should attempt to distinguish between the edema due to the service-connected varicose veins and that due to his nonservice-connected disorders. The examiner should note that that if a factual distinction between the service-connected varicose veins and any nonservice-connected disorder(s) cannot be made as a medical matter, then under applicable law all symptomatology will be presumed to be due to the service-connected disability. A clear rationale for all opinions expressed must be provided. 4. After any additional notification and/or development that the AOJ deems necessary is undertaken, the Veteran's claim should be readjudicated. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response by the Veteran and his representative. Thereafter, the case must be returned to the Board for further appellate consideration, if in order. The Veteran has the right to submit additional evidence and argument on this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).