Citation Nr: 1800879 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 16-18 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUES 1. Entitlement to an increased rating in excess of 30 percent prior to April 13, 2017, and in excess of 40 percent after April 13, 2017, for varicose veins of the right and left lower extremities. 2. Entitlement to service connection for a heart condition, to include as secondary to service-connected varicose veins. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Mariah N. Sim, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from December 1943 to February 1946. He is the recipient of the World War II Victory Medal, the Asiatic-Pacific Medal with two Bronze Stars, and the American Theater Medal. This matter comes to the Board of Veteran's Appeals (Board) on appeal from a November 2013 rating decision issued by Department of Veterans' Affairs (VA) Regional Office (RO) in Boston, Massachusetts. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue of entitlement to service connection for a heart condition, to include as secondary to service-connected varicose veins addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entire period on appeal, the Veteran's varicose veins were manifested by symptoms more nearly approximating a 60 percent disability rating. CONCLUSION OF LAW The criteria for an evaluation in excess of 40 percent, but not higher than 60 percent, for varicose veins, has been met or approximated for the entire period on appeal 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code 7120 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has considered the Veteran's claim and decided entitlement based on the evidence or record. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran contends he is entitled to an increased rating for his varicose veins, in excess of 30 percent prior to April 13, 2017, and in excess of 40 percent thereafter. For the reasons provided below, the Board finds that a rating in excess of 40 percent, but not higher than 60 percent, is warranted for the entire period on appeal. Pursuant to Diagnostic Code 7120, a 30 percent rating is warranted for varicose veins with persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; a 40 percent rating is warranted when there is persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; a 60 percent rating is warranted when there is persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration; and a 100 percent rating is warranted when there is massive board-like edema with constant pain at rest. At a November 2013 VA examination, the Veteran was noted to have bilateral lower extremity varicose veins with symptomatology including bilateral aching and fatigue in leg after prolonged standing or walking, bilateral symptoms relieved by elevation of extremity and compression hosiery, bilateral persistent stasis pigmentation or eczema, right lower extremity intermittent ulceration, bilateral persistent edema, and bilateral constant pain at rest. The Veteran was noted to have constant lower extremity pain due to his varicose veins, exacerbated by weight-bearing activities. The Veteran reported the constant use of a cane for assistance with ambulation. At an April 2017 VA examination, the Veteran was noted to have bilateral lower extremity varicose veins with symptomatology including bilateral aching in leg after prolonged standing and walking, bilateral fatigue in leg after prolonged standing and walking, bilateral symptoms relieved by elevation of extremity and compression hosiery, bilateral persistent stasis pigmentation, bilateral persistent eczema, right lower extremity intermittent ulceration, bilateral persistent edema, and bilateral persistent subcutaneous induration. The Veteran was noted to have highly symptomatic varicose veins, with pain that had worsened since the November 2013 VA examination, and a cluster of varicosities behind the right knee that were noted to be especially troublesome. The Veteran reported the constant use of a cane for assistance with ambulation. A May 2017 VA examination addendum noted that the Veteran's bilateral persistent edema is only incompletely relieved by elevation of the extremities, and is only incompletely relieved with compression stockings. The Board acknowledges that the results of the VA examinations, the symptoms described in the VA examination reports and the record does not indicate that the Veteran has experienced all of the symptoms associated with a 60 percent rating for varicose veins. Nevertheless, based on the totality of the evidentiary record, and resolving doubt in favor of the Veteran, the Board finds that the Veteran's symptomatology more nearly approximates a 60 percent rating for the entire period on appeal. A rating in excess of 60 percent is not warranted as the evidence does not show the Veteran has massive board-like edema with constant pain at rest or symptoms more nearly approximating the criteria for a 100 percent rating. ORDER For the entire period on appeal, a rating in excess of 40 percent, but not higher than 60 percent, for service-connected varicose veins of the left lower extremity, is granted. For the entire period on appeal, a rating in excess of 40 percent, but not higher than 60 percent, for service-connected varicose veins of the right lower extremity, is granted REMAND The Board finds that additional development is needed before the Veteran's claims on appeal can be decided. To date, the Veteran has not been provided a VA examination to determine the nature and likely etiology of his heart condition, to include as secondary to his service-connected varicose veins. An examination or medical opinion is warranted when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the Veteran has a heart condition, and claims it may be attributable as secondary to his varicose veins, the Board finds that a VA examination and opinion will assist in adjudicating the Veteran's claim. Therefore, on remand, a VA examination should be provided. Although the Board regrets the additional delay due to this remand, it finds that it is necessary in order to ensure that there is a complete record upon which to decide the Veteran's claim. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (2017). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his heart condition, to include as secondary to his service-connected varicose veins. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should elicit a relevant history from the Veteran in connection with the examination. Following review of the record, the examiner(s) should opine as to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's heart condition manifested in service or are otherwise causally or etiologically related to his military service. The examiner should also opine as to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's heart condition is caused or aggravated by his service-connected varicose veins. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner(s) should provide a fully reasoned explanation. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Thereafter, the AOJ should review the opinion to ensure that it is responsive and in compliance with the directives of this remand. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. 3. After completing the above, and any other development deemed necessary, the AOJ should readjudicate the claim based on the entirety of the evidence. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) 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. §§ 5109B, 7112 (2012). _________________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs