Citation Nr: 18155608 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-41 369 DATE: December 4, 2018 ORDER A disability rating in excess of 10 percent for mastocytosis is denied. FINDING OF FACT Throughout the appeal period, the Veteran’s mastocytosis has required continuous medication for control; hemoglobin of less than 10gm/100ml or the requirement of transfusion of platelets or red blood cells has not been demonstrated. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for mastocytosis are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.117, Diagnostic Codes 7700, 7703, 7716. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1967 to September 1970, to include service in the Republic of Vietnam. In a November 2015 Form 9, the Veteran requested a hearing before the Board of Veterans’ Appeals (Board). This request was withdrawn in October 2018. Disability ratings are determined by applying the criteria set forth in the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (Rating Schedule), and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Mastocytosis does not appear in the Rating Schedule, and therefore must be rated under a related disease in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Evidence suggests that mastocytosis, or mast cell disease, is similar to leukemia, which is rated under Diagnostic Code (DC) 7703. DC 7703 provides that a 100 percent rating is warranted with active disease or during the treatment phrase. Otherwise, the adjudicator is to rate the disability as anemia (DC 7700) or aplastic anemia (DC 7716), whichever would result in the greater benefit. Under DC 7700, a non-compensable rating is warranted for hypochromic-microcytic and megaloblastic anemia with hemoglobin 10gm/100ml or less, asymptomatic. A 10 percent rating is warranted for hypochromic-microcytic and megaloblastic anemia with hemoglobin 10gm/100ml or less with finding such as weakness, easy fatigability or headaches. A 30 percent rating is warranted for hypochromic-microcytic and megaloblastic anemia with hemoglobin 8gm/100ml or less with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath. A 70 percent rating is warranted for hypochromic-microcytic and megaloblastic anemia with hemoglobin 7gm/100ml or less with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute) or syncope (three episodes in the last six months). A 100 percent rating is warranted for hypochromic-microcytic and megaloblastic anemia with hemoglobin 5gm/100ml or less, with findings such as high output congestive heart failure or dyspnea at rest. Alternatively, under DC 7716, for a 10 percent rating, the evidence must show a diagnosis of aplastic anemia requiring continuous medication for control. For a 30 percent rating, there must be a diagnosis of aplastic anemia requiring transfusion of platelets or red cells at least once per year, but less than once every three months, or; infections recurring at least once per year, but less than once every three months. For a 60 percent rating, there must be a diagnosis of aplastic anemia requiring transfusion of platelets or red cells at least every three months, or; infections recurring at least once every three months. For a 100 percent rating, there must be a diagnosis of aplastic anemia requiring bone marrow transplant, or; requiring transfusion of platelets or red cells at least once every six weeks, or; infections recurring at least once every six weeks. Turning to the evidence, the Veteran filed a claim for service connection for mastocytosis in November 2012. This benefit was granted in a July 2015 Board decision. Thereafter, in a July 2015 rating decision, the Regional Office (RO) assigned a noncompensable rating considering findings at a December 2012 VA examination of easy fatiguability, headaches and hemoglobin more than 10gm/100ml. In an August 2015 notice of disagreement, the Veteran indicated he was experiencing muscle and joint pain along with occasional mild to moderate abdominal discomfort. In a statement submitted in October 2015, the Veteran indicated his mastocytosis was under quasi-control, but still an active disease. He was experiencing weakness, easy fatigability, shortness of breath and lightheadedness. In October 2015, the Veteran submitted an unsigned Hematologic and Lymphatic Conditions Disability Benefits Questionnaire. It was noted he was taking daily medication to control symptoms of mastocytosis. The Veteran did not report any complications or residuals of treatment requiring transfusion of platelets or red blood cells. The Veteran indicated experiencing spells causing general weakness and shaking, heavy sweating and headaches and difficulty breathing around fragrances. Fragrances were said to cause “brain fog” and headaches. He submitted a statement from Dr. A., an academic hematologist/oncologist who specialized in mast cell disease. Dr. A. indicated review of records the Veteran sent him. He stated symptoms from systemic mastocytosis had steadily escalated over the years. He explained that his summaries were generally accepted knowledge in modern medical literature and his assertions about the course of the Veteran’s disease were educated guesses based on the medical records that were provided. He stated he had not formally medically evaluated the Veteran. In November 2015, the Veteran underwent a VA examination for loss of sense of taste and smell. It was noted that if the Veteran sat next to someone with strong perfume, he would experience headaches, dizziness, joint pain and shaking. The examiner stated that mast cell disease is closely associated with intranasal physiology and release of mast cell products into the blood stream which cause the type of systemic symptoms the Veteran reported. In November 2015, the Veteran also underwent a Hematologic and Lymphatic Conditions examination. His condition remained active and he regularly took medication to help mitigate symptoms. He reported chronic fatigue, dizziness, lightheadedness, headaches, and generalized aches and pains. He reported his skin was sensitive with rashes at times. Exposure to fragrances greatly aggravated his symptoms. The Veteran had no complications or residuals of treatment requiring transfusion of platelets or red blood cells. He indicated weakness, easy fatigability especially in hot weather, light-headedness, shortness of breath, headaches, and dyspnea on mild exertion when exposed to fragrances. A history of osteopenia was also noted as being related to the condition with mild generalized aches and pains. Hemoglobin was noted to be 15.2 in April 2015. A compensable rating was denied in the November 2015 statement of the case because the Veteran’s hemoglobin was not below normal levels. In December 2015, the Veteran submitted a statement from a registered nurse who was a member of The Mastocytosis Society. She explained that mastocytosis is similar to leukemia in that the mast cell, which is created in the bone marrow, overproduces abnormally. She noted the Veteran’s health was not expected to improve and his current quality of life was severely inhibited. In January 2016, an opinion was sought due to the Veteran’s contention that his condition should not be rated analogous to anemia, as it was more similar to chronic leukemia. An examiner was asked to review the record to indicate whether the Veteran’s condition was more similar to leukemia or anemia, agranulocytosis or other disability found in the hemic/lymphatic section of diseases. The examiner indicated a thorough review of the record and queried a prominent hematologist/oncologist concerning the disease. He opined that mastocytosis “falls under an allergy type lineage.” He stated that “very, very rare” cases of severe mastocytosis could progress to leukemic states, but that was an exception to the rule and that a review of the clinical records did not support that the Veteran suffered from a severe level of mastocytosis that would incorporate true chronic leukemia. He indicated that whether the Veteran’s condition would ever progress to the leukemic state was unknown. In March 2016, a Decision Review Officer (DRO) made a request for an independent medical opinion (IMO) to the Director of the Compensation & Pension Service. In April 2016, it was determined an IMO was not warranted because the examination and private medical opinions of record clearly stated that mastocytosis was either a non-malignant neoplasm or allergy-type condition and there was sufficient medical evidence to rate it in the Veteran’s case without requesting an additional opinion. In a July 2016 Report of General Information, it was indicated a DRO conference was held and the Veteran’s representative sought a 30 percent evaluation under DC 7700 due to the fatiguability, headaches, light headedness and dizziness the Veteran was experiencing. In a September 2016 statement in support of claim, the Veteran reported he experienced chronic fatigue, dizziness, light headedness, headaches, brain fog and generalized aches and pains due to mastocytosis. He also experienced chronic mild weakness, fatigue and headaches that worsened at times with exposure to fragrances. He indicated exacerbations four to five times per week, lasting 30 minutes to three hours. He listed multiple medications he was using to control his symptoms and stated he always carried an epi-pin because anaphylaxis was a worry for him. In a February 2017 supplemental statement of the case, the RO increased the Veteran’s initial rating to 10 percent under DC 7716 due to the condition requiring continuous medication for control. Based on review of the record, the Board finds that rating under DC 7703, for leukemia, with consideration of both DC 7700 and DC 7716 is appropriate for the Veteran’s mastocytosis and considers the Veteran’s desire for a rating under DC 7700. As noted, DC 7703 directs that in the absence of active leukemia, which is not demonstrated here, a condition should be rating under DC 7700 or DC 7716 whichever would result in the greater benefit. Here, the evidence does not support a compensable rating under DC 7700 despite the Veteran’s symptoms of weakness, easy fatiguability, headaches, lightheadedness and shortness of breath because a compensable rating requires hemoglobin of 10gm/100ml or less. At no time during the appeal period has the Veteran’s hemoglobin been less than 10gm/100ml and the Veteran does not make such a contention. A 10 percent rating under DC 7716 is warranted for the entire appeal period as the record reflects the Veteran requires continuous medication for control of his mastocytosis symptoms. A rating in excess of 10 percent is not warranted under DC 7716 as the Veteran has not required transfusion of platelets or red blood cells or a bone marrow transplant due to his mastocytosis. The Board finds no other appropriate diagnostic code which would provide for a higher rating and notes that the Veteran is already receiving a separate 30 percent rating for the headaches associated with his mastocytosis. In summary, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for mastocytosis and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Counsel