Citation Nr: 1422085 Decision Date: 05/15/14 Archive Date: 05/29/14 DOCKET NO. 08-09 871 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for hypothyroidism with cardiac arrhythmia, status post thyroidectomy for thyroid papillary cancer [herein hypothyroidism]. REPRESENTATION Appellant represented by: Armed Forces Service Corporation ATTORNEY FOR THE BOARD S. Hoopengardner, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1986 to February 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted entitlement to service connection for hypothyroidism, status postoperative thyroidectomy for thyroid papillary cancer and established a 10 percent disability rating, effective the day following separation from service in March 2007. The Veteran's case was transferred to the Roanoke, Virginia RO based on the Veteran's place of residence. A subsequent February 2008 Decision Review Officer (DRO) decision granted the Veteran a 30 percent disability rating, effective March 2007. In September 2011 and December 2013, the Board remanded the Veteran's claim for further development, which has been completed, and the case has been returned to the Board for appellate consideration. The Veteran initially requested a hearing before a Veterans Law Judge in Washington, D.C., but withdrew that request in a May 2011 correspondence. Subsequent to the last Supplemental Statement of the Case (SSOC) issued in March 2014, the Veteran submitted an additional private medical record without waiver of Agency of Original Jurisdiction review. This evidence has been reviewed and is deemed duplicative of the evidence already of record. Therefore, there is no prejudice for the Board to proceed. A review of the electronic records maintained in Virtual VA and Veterans Benefits Management System (VBMS) was conducted. FINDINGS OF FACT 1. Prior to February 13, 2012, the Veteran's service-connected hypothyroidism was manifested by mental disturbance and weight gain, but was not manifested by muscular weakness. 2. From February 13, 2012, the Veteran's service-connected hypothyroidism has been manifested by muscular weakness, mental disturbance, and weight gain. Dementia and bradycardia (less than 60 beats per minute), have not been shown. CONCLUSIONS OF LAW 1. Prior to February 13, 2012, the criteria for a 30 percent disability rating for the Veteran's hypothyroidism have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.119, Diagnostic Code 7903 (2013). 2. Resolving reasonable doubt in the Veteran's favor, from February 13, 2012, the criteria for a 60 percent disability rating, but no higher, for the Veteran's hypothyroidism have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.119, Diagnostic Code 7903 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions with respect to the Veteran's claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). This appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for hypothyroidism. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C.A. § 5103A (West 2012); 38 C.F.R. § 3.159(c) (2013). The RO associated the Veteran's service treatment records and adequately identified private medical records with the claims file. As such, the Board finds that VA has satisfied its duty to assist with the procurement of records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 C.F.R. § 3.159(c) (4) (2013). The Veteran was provided with VA examinations in September 2006, July 2008, September 2009, February 2012, June 2013 and February 2014. The September 2011 Board remand found the September 2009 VA examination to be deficient and the December 2013 Board remand found the June 2013 VA examination to be deficient. The Board finds that the February 2014 VA examination report to be thorough, complete and a sufficient bases upon which to reach a decision on the Veteran's claim. See Rodriguez-Nieves v. Peake, 22 Vet. App. 295, 302-05 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Since VA has obtained all relevant identified records and provided an adequate medical examination, its duty to assist with respect to the Veteran's claim is satisfied. II. Initial Disability Rating in Excess of 30 Percent The Veteran contends that an initial disability rating in excess of 30 percent for her service-connected hypothyroidism is warranted. Legal Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2012); 38 C.F.R. Part 4 (2013). In cases such as this, where the Veteran appeals the initial rating assigned for a service-connected disability, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected hypothyroidism is rated under Diagnostic Code 7903. Under this diagnostic code, a 30 percent disability rating is warranted when there is fatigability, constipation, and mental sluggishness. A 60 percent disability rating is warranted when there is muscular weakness, mental disturbance, and weight gain. A 100 percent disability rating is warranted when there is 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, Diagnostic Code 7903 (2013). Analysis The Veteran initially filed a claim for thyroid cancer (thyroidectomy) in August 2006. The Veteran was afforded a VA examination in September 2006. The examination report noted that the Veteran stated "she is suffering from residuals secondary to malignancy or treatment, such as weight gain, heart palpitations, hair loss, memory changes due to hypothyroid state". The examination report also stated that "[a]s a result of her thyroid condition, she has suffered fatigability, sleepiness, emotional instability, depression, slowing of thought, poor memory, difficulty breathing, difficulty swallowing and heart palpitations, weight gain, hair loss, high LDL levels, and high blood pressure" and that "[s]ince the removal of her thyroid cancer she has had all these[] problems on a daily basis". The examination report further noted that the Veteran had an intolerance of cold and hot weather. The examination report noted that the Veteran's thyroid condition has resulted in heart problems consisting of frequent heart palpitations. The examination report noted that the thyroid condition affects body weight and that the Veteran's weight went from 160 pounds to 195 pounds within a 6 month period. The examination report further noted that the Veteran's thyroid condition has resulted in "gastrointestinal problems consisting of problems with digestions, heart burn" and that the thyroid condition has "affected voice sometimes gets low and it is hard to speak, and has elevated blood pressure." The examination reported noted that the Veteran's treatment included Levothroid daily. The examination report noted that the thyroid condition caused functional impairment due to constant fatigue, poor memory, unable to sleep at night, depression, hard to catch breath, hard to swallow and nervousness. Upon physical examination, under the musculoskeletal system section the examiner noted that "[t]he condition does not cause generalized muscle weakness". The examination report included a diagnosis of hypothyroidism secondary to thyroidectomy for thyroid papillary cancer and listed subjective factors as fatigue, weight gain, hair loss and memory changes, with objective factors of surgical scar, medical record review, thyroid function test results. A May 2007 rating decision granted service-connection for hypothyroidism, status postoperative thyroidectomy for thyroid papillary cancer and assigned a 10 percent rating, effective the day following separation from service in March 2007. The Veteran filed a Notice of Disagreement with respect to this rating decision in September 2007. In a November 2007 statement, the Veteran requested a DRO review of her appeal. A February 2008 Decision Review Officer (DRO) decision increased the Veteran's disability rating for her service-connected hypothyroidism condition to 30 percent, effective March 2007. The DRO decision listed weight gain, continued medication and fatigue as reasons why a 30 percent disability rating was assigned. In the Veteran's April 2008 Form 9, completed by the Veteran's representative, the representative referenced the criteria for a 60 percent disability rating under Diagnostic Code 7903 (muscular weakness, mental disturbance and weight gain) and stated that the Veteran "now reports these symptoms and will provide additional medical evidence to support her claim". In the same November 2007 statement discussed above, the Veteran stated that she "suffer[s] daily with my hypothyroidism with weight gain, mood swings, lack of energy, hair loss, problems with bowel movements" and heart palpitations. In this statement, the Veteran also requested service-connection for "irregular heart beats". The Veteran was afforded a VA examination in July 2008, which included a diagnosis of cardiac arrhythmia. A cardiac test was conducted and a METs level of 13.5 was reported. An October 2008 rating decision recharacterized the Veteran's condition as hypothyroidism with cardiac arrhythmia (claimed as irregular heart beat), status postoperative thyroidectomy for thyroid papillary cancer and continued the 30 percent disability rating. In an August 2009 statement, the Veteran's representative stated that the Veteran's hypothyroidism was worse. The Veteran was afforded a VA examination in September 2009. The examination report stated that "[a]s a result of [the Veteran's] thyroid condition, she describes fatigability, sleepiness, tremor, emotional instability, depression, slowing of thought, poor memory, difficulty breathing and hair loss, weight gain". The examination report showed that the Veteran complained of an intolerance of cold and hot weather. With respect to weight gain, the examination report noted that the Veteran has gained 55 pounds over the last 5 years. The examination report stated that the Veteran's "thyroid condition has resulted in heart problems consisting of heart palpations, frequent and gastrointestinal problems consisting of constant gas" and that the "thyroid condition has affected the heart palpitations". The examination reported noted that the Veteran is on Synthroid and that "[t]he following symptoms are non responsive to therapy or treatment: weight gain, hair loss, heart palpitations, mood, fatigue, depression". The examination report stated that the side effects of treatment include "weight gain, hair loss, heart palpitations, mood, fatigue, depression". The examination report further stated that the Veteran reported "the following overall functional impairment(s): [d]ifficulty remembering, moody, constantly fatigued/tired, sleepless nights, constantly wakes up during night." With respect to the Veteran's arrhythmia, the examination reported noted that the Veteran' had experienced shortness of breath, dizziness and fatigue and that the "[t]he ability to perform daily functions during flare-ups" includes feeling dizzy, nervous and hard to speak. Upon physical examination, under the musculoskeletal system section the examiner noted that "[t]he condition does not cause generalized muscle weakness". The diagnosis section reported no change to the Veteran's hypothyroidism diagnosis and listed subjective factors as "history" and objective factors as "scar on exam". In an October 2009 statement, the Veteran stated that her heart palpitations occur several times a week and that they make her feel dizzy and nervous and that she loses her breath, which makes it hard to speak. In a May 2010 statement, the Veteran reported that after her thyroid cancer, she has had the following health problems: hair loss, heart palpitations, weight gain, memory loss, mood swings, depression, trouble sleeping, high blood pressure and vitiligo (which the Board notes the Veteran was granted service connection for in a July 2010 rating decision as secondary to her service-connected hypothyroidism). The Veteran's representative submitted an Informal Hearing Presentation (IHP) in June 2011, which stated under Diagnostic Code 7903 the Veteran should be entitled to a 100 percent disability rating. The IHP further stated that "[t]he veteran stated that the medications she is taking are triggering the extra symptoms" and that "[t]his information was never considered by the medical examiner and she was therefore denied the elevated ratings". The Veteran submitted a June 2011 statement to the Board. The Veteran stated that she was found to have a cancerous enlarged thyroid in 2002 that resulted in a thyroidectomy and radioactive iodine treatment. The Veteran stated that since 2002, she has "been cancer free but not without the side effects that have resulted from the removal of my thyroid, and from taking my prescribed medication." She stated that she now suffers from constant weight gain, heart palpitations, high blood pressure, high cholesterol, memory loss, unexplained mood changes, irritability, severe hair loss result in blading patches, vitiligo, intolerance to cold and heat, anxiety, trouble sleeping, fatigue, constant constipation and "muscle and painful joints". The Veteran stated that her condition requires her to take Synthroid, which she feels is causing the above side effects. In September 2011 the Board remanded the Veteran's hypothyroidism claim because the September 2009 examination report was deficient in that, while it recorded the Veteran's self-reported symptoms, "the examiner did not indicate if there was any actual objective evidence on examination of the presence or absence of any of these symptoms". The Board remanded for a new VA examination to determine whether there was objective evidence of any of the symptoms listed in Diagnostic Code 7903. The Veteran was afforded a VA examination on February 13, 2012. The examination report was conducted using the Thyroid and Parathyroid Conditions Disability Benefits Questionnaire (DBQ). Under the diagnosis section, the examiner indicated a diagnosis of papillary thyroid cancer. Under the medical history section, the examiner described the history of the Veteran's thyroid condition as "[s]tatus post thyroidectomy (total)". The examiner indicated that continued medical (Synthroid) is required to control the Veteran's thyroid condition. In response to a question about whether the Veteran has any residual endocrine dysfunction following treatment for thyroid condition, the examiner indicated yes and listed hair loss, weight gain and memory issues. The examiner indicated that the Veteran had findings, signs or symptoms attributable to a hyperthyroid condition and indicated intermittent tachycardia (more than 100 beats per minute), palpitations, emotional instability, fatigability and muscular weakness. The examiner also indicated that the Veteran had findings, signs or symptoms attributable to a hypothyroid condition and indicated fatigability, constipation and mental sluggishness. The examiner indicated that the Veteran's thyroid condition had no impact on her ability to work. The examiner also completed a Heart Conditions DBQ, which included a diagnosis of palpitations and provided an interview-based METs test that showed fatigue occurred at greater than 3 but not greater than 5 METs. The examiner noted that the METs level limitation is not solely due to the Veteran's heart condition, but did not estimate what percent of the METs level limitation is due solely to the heart condition. In a June 2013 statement, the Veteran indicated that her thyroid condition had started to affect other medical conditions, including diastolic dysfunction, high blood pressure, peptic ulcers, eye problems, and spreading vitiligo. She mentioned symptoms of being constantly tired, unable to maintain my weight, mental sluggishness, muscle weakness and constipation. The Veteran was afforded a VA examination in June 2013 and the examiner completed the Thyroid and Parathyroid Conditions DBQ. The examiner noted a diagnosis of hypothyroidism and that the Veteran requires continuous medication (Synthroid) for control of her thyroid condition. The examiner indicated that the Veteran did not have any residual endocrine dysfunction following treatment for the thyroid condition and that the Veteran did not have any findings, signs or symptoms attributable to a hyperthyroid condition. The examiner indicated that the Veteran did have findings, signs or symptoms attributable to a hypothyroid condition and noted palpitations. In the remarks section, the examiner indicated that the Veteran's diagnosis had not changed. The examiner also completed a Hypertension DBQ. The Veteran was granted entitlement to service connection for hypertension as secondary to her service-connected hypothyroidism in a February 2011 DRO decision, with an effective date of August 2007. The February 2011 DRO decision granted secondary service-connection for hypertension "because cardiac involvement is considered part of the criteria used to evaluate hypothyroidism and is a common complication of thyroid disorders". On the June 2013 Hypertension DBQ, in the medical history section, the DBQ stated "specific history for: hypertension associated with hypothyroidism" and the examiner stated that "[t]he condition has gotten worse and is beginning to develop several other medical condition, weight gain, mental sluggishness, constantly tired, constipation, hair loss, intolerant to heat/cold." In December 2013 the Board remanded the Veteran's hypothyroidism claim because the previous September 2011 remand directives were not complied with, specifically that the July 2013 VA examination was deficient in that there was "no indication of what objective evidence, testing or clinical observations underlay [the examiner's] 'conclusions'". The Veteran was afforded a VA examination in February 2014 and the examiner completed the Thyroid and Parathyroid Conditions DBQ. In the diagnosis section, the examiner indicated a diagnosis of hypothyroidism. Under the medical history section, the examiner noted that the Veteran stated that since the last VA examination, her "symptoms have persisted and she has noticed worsening in both short term and long term memory, worsening of constipation, and cold/heat intolerance and palpitations". The examiner noted that the Veteran currently takes Synthroid. In reference to constipation, the examiner stated "takes fiber. If she does not take it, once a week. When she takes the fiber, every 3 days she has a bowel movement." In reference to cold/heat tolerance, the examiner stated "states she is constantly hot or too cold." In reference to memory loss, the examiner stated "states she has trouble remembering tasks and dates. States if she [does not] write it down, she forgets things. Folstein mini mental exam today is 25 (normal is 23-30)." In reference to muscle weakness, the examiner stated "states she used to work out, now she feels like she will drop the weight. Muscle strength today is 5/5 and grip is normal." The examiner noted that the Veteran had hypothyroid endocrine dysfunction as residual endocrine dysfunction following treatment for a thyroid condition. The examiner indicated that the Veteran did not have any findings, signs or symptoms attributable to a hyperthyroid condition. The examiner indicated that the Veteran had findings, signs or symptoms attributable to a hypothyroid condition and indicated fatigability, constipation, mental sluggishness, depression, slowing of thought, muscular weakness, weight gain and cold intolerance. The examiner indicated that the Veteran's thyroid condition impacts her ability to work and stated that "she has been having trouble with work because of memory loss" and that she forgets to do things for projects and has to constantly write notes to remind herself what to do. In an April 2014 statement, the Veteran responded to the March 2014 SSOC, which denied a disability rating in excess of 30 percent for hypothyroidism. The Veteran stated that "[s]ince my retirement I have received medical treatment that documents my complaints of mental disturbances/sluggishness, muscle weakness, inability to control body temperature, weight gain, heart palpations, hair loss, constipation, and fatigability." She then specifically addressed the three criteria under Diagnostic Code 7903 for a 60 percent disability rating. With regards to weight gain, the Veteran stated that "before my diagnosis of thyroid cancer and thyroidectomy I have since yearly gained weight and have NOT been able to lose the weight despite my many attempts", that "despite my many attempts to work out and manage my diet that I am unable to lose the weight", that "I have unsuccessfully tried many different methods to lose weight all of which have failed" and that "[m]y medical examinations over the last few years constantly show[n] my increase in weight". The Veteran also referenced the February 2014 VA examination where the examiner stated that the Veteran "feels like she will drop the weight" and indicated that she did not say that. Upon review, that particular statement was in the examination report section discussing muscle weakness and it appears that the examiner was referencing a weight used to exercise and not referencing the Veteran ability to lose weight. With regards to mental disturbance, the Veteran described her "daily struggle to remember/retain information" and gave examples of her memory problems. The Veteran stated that during the February 2014 VA examination, the examiner "tested my memory by seeing if I could remember something she said earlier in our conversation, when she asked if I could recall those words I could not remember them, and it had only been 5 minutes later." With regard to muscular weakness, the Veteran stated that her "muscular strength has deteriorated" and that she has "difficulty lifting objects weighing over 10lbs without the risk of dropping the item". The Veteran further stated that she loves to lift weights, but that she has "not been able to safely do so for a few years now". She also stated that she thinks it is "unfair to judge my muscular weakness based off one 15 minute office visit with the VA examiner. The examiner tested my muscular weakness by having me to push against her hands, (which I'm not sure how this would be an accurate measurement of muscular weakness) and from this one test my whole claim of muscular weakness has been disregarded, despite my numerous complaints to previous VA examiner's, my primary care, and endocrinologist." The Veteran further stated that she has "been complaining of muscular weakness, mental disturbance, and weight gain for several years (all of which are evident in my medical history)" and that "[t]he disapproval of the higher rating I feel is unfair and only based off one isolated visit with the VA examiner and discrediting the medical examinations of 3 other qualified medical professionals". The Veteran also stated that she has the following symptoms "horrible-frightening brain fog, forgetfulness, constant joint and muscle aches and pains, trouble sleeping, depression, weight gain, cold, extreme chronic tiredness, hair loss, nervousness, low vitamin D levels, muscle weakness" and "numerous other symptoms that will only continue to worse as I age." Based on the a review of the evidence, the Board finds that prior to February 13, 2012, entitlement to a disability rating in excess of 30 percent for hypothyroidism is denied, and resolving reasonable doubt in favor of the Veteran, from February 13, 2012, entitlement to a disability rating of 60 percent, but no higher, for hypothyroidism is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.119, Diagnostic Code 7903 (2013). A 60 percent disability rating under Diagnostic Code 7903 requires muscular weakness, mental disturbance and weight gain. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). While the 100 percent disability rating includes as part of mental disturbance symptoms of dementia, slowing of thought and depression, the 60 percent disability rating does not include those symptoms. The Veteran's initial September 2006 VA examination stated that "[a]s a result of her thyroid condition, she has suffered...depression, slowing of though" and "weight gain". The February 2014 VA examination noted that depression, slowing of thought and weight gain were all attributable to the Veteran's hypothyroid condition. Both the September 2006 and February 2014 VA examination noted slowing of thought and depression, as well as other mental symptoms, and thus the Board finds that the Veteran's service-connected hypothyroidism has been manifested by mental disturbance as contemplated by the 60 percent disability rating under Diagnostic Code 7903. The Board finds these two examination reports highly probative and finds that the Veteran's service-connected hypothyroidism has been manifested by weight gain and mental disturbance throughout the period on appeal. The remaining symptom required for a 60 percent disability rating under Diagnostic Code 7903 is muscular weakness. The September 2006 VA examination was silent as to complaints of muscular weakness and noted under the musculoskeletal system section that "[t]he condition does not cause generalized muscle weakness". The September 2009 VA examination, which the September 2011 Board remand found to be deficient, also was silent as to muscular weakness and included the same note under the musculoskeletal system section that "[t]he condition does not cause generalized muscle weakness". The February 13, 2012 VA examination did note muscular weakness, but noted it as a symptom attributable to a hyperthyroid condition, as opposed to a hypothyroid condition. The June 2013 VA examination, which the December 2013 Board remand found to be deficient, was silent as to muscular weakness. The February 2014 VA examination did include a finding of muscular weakness attributable to the Veteran's hypothyroid condition, though the examiner reported that the Veteran's muscle strength was 5/5 and the grip was normal. Looking to the Veteran's statements, the Veteran frequently included a long list of symptoms she was experiencing, but the Veteran did not mention muscular weakness in her November 2007 statement, May 2010 statement or June 2011 statements. The Veteran's June 2013 statement is the first statement to VA where she reported muscular weakness. In her April 2014 statement, the Veteran referenced "numerous complaints [of muscular weakness] to previous VA examiner's, my primary care, and endocrinologist" and that she has "been complaining of muscular weakness...for several years (all of which are evident in my medical history)". As discussed above, however, the first VA examination to reference muscular weakness was not until February 2012 and the first statement from the Veteran to VA to reference muscular weakness was not until June 2013. In the April 2008 Form 9, the Veteran's representative referenced the criteria for a 60 percent disability rating under Diagnostic Code 7903 (muscular weakness, mental disturbance and weight gain) and stated that the Veteran "now reports these symptoms and will provide additional medical evidence to support her claim". Medical evidence to this effect was not received and in fact private medical records associated with the Veteran's file are contrary to the representative's assertions. A November 2010 record from Dr. H.T. noted that muscle weakness was not present. A February 2013 record from Dr. N.J noted, under the musculoskeletal section, that the Veteran denied muscle weakness. A March 2013 record from Dr. G.A., under the musculoskeletal section, noted strength grossly normal and showed that the Veteran complained of joint aches. A May 2013 record from Dr. T.S., under the musculoskeletal section, noted that the overall assessment of muscle strength and tone was grossly intact for the upper and lower extremities. Resolving doubt in the Veteran's favor, the Board finds that the evidence of record reflects that the Veteran's service-connected hypothyroidism was manifested by muscular weakness from February 13, 2012, the date of the examination where muscular weakness was first documented by a medical professional. While the examiner indicated muscular weakness as a symptom attributable to a hyperthyroid condition, as the other evidence of record has been silent as to any hyperthyroid conditions throughout the period on appeal, resoling doubt in favor of the Veteran, the Board finds that the examiner made a mistake and this symptom should have been attributed to the Veteran's service-connected hypothyroidism. With regards to the private medical records discussed above subsequent to the February 13, 2012 VA examination, the Board finds the February 13, 2012 VA examination to be more probative as to the manifestation of muscular weakness. The Board notes that in the Veteran's April 2014 correspondence, she "address[ed] the additional denied complaints of (mental disturbance, muscle weakness, weight gain) which I feel supports being warranted the higher evaluation of 60 percent", which suggests that the Veteran is seeking a 60 percent disability rating for her service-connected hypothyroidism, which as discussed above, has been granted from February 13, 2012. Regardless of the Veteran's statements, the Veteran's hypothyroidism, from February 13, 2012, does not more nearly approximate the next higher 100 percent disability rating. A 100 percent disability rating is warranted when there is 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, Diagnostic Code 7903 (2013). The Veteran has complained of cold intolerance and sleepiness, and as discussed above, from February 13, 2012 her service-connected hypothyroidism has been manifested by muscular weakness. Also, cardiovascular involvement is present, as the Veteran has been service connected for hypertension secondary to her service-connected hypothyroidism and the Veteran's complaints of heart palpitations are reflected in her service-connected hypothyroidism as cardiac arrhythmia. The Veteran has not, however, complained of or been diagnosis with bradycardia (less than 60 beats per minute). Also, while the Veteran has the mental disturbance sufficient for a 60 percent disability rating, as discussed above, mental disturbance is not defined as part of the 60 percent disability rating, whereas for the 100 percent rating the symptoms of dementia, slowing of though and depression are included. While the Veteran has complained of depression and slowing of thought, which also have been shown in medical records, the Veteran has not complained of or been diagnosed with dementia. As such, the Veteran does not have mental disturbance as contemplated by the 100 percent disability rating. Since the Veteran does not meet all of the listed criteria for a 100 percent disability rating, specifically mental disturbance (dementia, slowing of thought, depression) and bradycardia (less than 60 beats per minute), a 100 percent rating is not warranted. The Board has also considered rating the Veteran's service-connected hypothyroidism under other appropriate diagnostic codes. The Board notes that part of the Veteran's service-connected hypothyroidism is cardiac arrhythmia. Diagnostic Code 7011 is applicable to sustained ventricular arrhythmias and the RO evaluated the Veteran's condition under this code in the February 2011 SSOC. A 60 percent disability rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for an indefinite period from the date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia, or; for an indefinite period from the date of hospital admission for ventricular aneurysmectomy, or; with an automatic implantable Cardioverter-Defibrillator (AICD) in place or for chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction (LVEF) of less than 30 percent. The July 2008 VA examination, which included a diagnosis of cardiac arrhythmia, conducted a cardiac test and a METs level of 13.5 was reported. Based on this MET level and that no episodes of acute congestive heart failure were reported, prior to February 13, 2012, a rating in excess of 30 percent is not warranted under Diagnostic Code 7011. The February 13, 2012 VA examination, which is the date from which the Veteran has been assigned a 60 percent rating under Diagnostic Code 7903, included a diagnosis of palpitations and provided an interview-based METs test that showed fatigue occurred at greater than 3 but not greater than 5 METs. The exam conducted an EKG and chest x-ray, which both were noted as normal and thus no echocardiogram was done and LVEF was not reported. The examiner noted that the METs level limitation is not solely due to the Veteran's heart condition, but did not estimate what percent of the METs level limitation is due solely to the heart condition. Even assuming that the Veteran's METs level limitation was solely due to the Veteran's heart condition, which the examiner stated it was not, the MET level provided would not warrant a 100 percent disability rating under Diagnostic Code 7011. In addition, throughout the period on appeal, there has been no evidence that the Veteran was hospitalized for her cardiac arrhythmia, that she has an AICD in place or that there was a LVEF of less than 30 percent. In sum, throughout the period on appeal, a higher rating than assigned under Diagnostic Code 7903 is not warranted under Diagnostic Code 7011, or any other diagnostic code. Extraschedular Rating Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." See id. at 115. In order to determine whether a disability is "exceptional or unusual," there "must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id. Neither the first nor second Thun element is satisfied. The Veteran's service-connected hypothyroidism is manifested, throughout the appeal period, by signs and symptoms such as mental disturbance and weight gain, and from February 13, 2012, also manifested by muscular weakness. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule and the Diagnostic Code under which the Veteran is rated. 38 C.F.R. § 4.119, Diagnostic Code 7903 (2013). Accordingly, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. In short, there is nothing exceptional or unusual about the Veteran's hypothyroidism because the rating criteria reasonably describe her disability level and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that her service-connected hypothyroidism has caused marked absence from work or resulted in frequent hospitalizations. Thus, even if her disability picture was exceptional or unusual, referral would not be warranted. In conclusion, the evidence of record does not warrant referral for an extraschedular rating. Total Evaluation Based on Individual Unemployability (TDIU) A claim for a total disability rating based on individual unemployability is part and parcel of an increased rating claim, when such a claim is raised by the record. See Rice v. Shinseki, App. 447 (2009). Here, the Veteran has not asserted that she is no longer able to work because of symptomatology associated with her service-connected hypothyroidism. To the contrary, the February 2014 VA examination stated that the Veteran works in human resources. Therefore, a claim of TDIU is not before the Board. (CONTINUED ON NEXT PAGE) ORDER Prior to February 13, 2012, entitlement to a disability rating in excess of 30 percent for hypothyroidism is denied. From February 13, 2012, entitlement to a disability rating of 60 percent, but no higher, for hypothyroidism is granted. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs