Citation Nr: 18156919 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-59 984 DATE: December 11, 2018 ORDER Entitlement to a rating in excess of 30 percent for residuals of fibroid cysts, post hysterectomy is denied. REMANDED Entitlement to service connection for skin lesions is remanded. Entitlement to a rating in excess of 70 percent for major depressive disorder is remanded. Entitlement to a compensable rating for abdominal scars is remanded. Entitlement to special monthly compensation based on housebound status is remanded. Entitlement to special monthly compensation based on the need for aid and attendance is remanded. FINDING OF FACT In treatment of fibroid cysts, the Veteran had a hysterectomy which removed her uterus, but not her ovaries. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for residuals of fibroid cysts, post hysterectomy have not been met or approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 4.3, 4.116, Diagnostic Code 7618. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1980 to February 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November 2015 and June 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Although the Veteran requested a hearing before a member of the Board on her November 2017 VA Form 9, she withdrew her hearing request in December 2017. Therefore, the Board finds that there is no hearing request pending. Increased Rating Entitlement to a rating in excess of 30 percent for residuals of fibroid cysts, post hysterectomy The Veteran contends that she is entitled to rating in excess of 30 percent for residuals of fibroid cysts, post hysterectomy. Specifically, she believes she is entitled to at least a 45 percent or 90 percent rating. See January 2016 Notice of Disagreement and January 2017 correspondence. Diagnostic Code 7618 provides that a 100 percent evaluation is warranted for three months following the removal of the uterus. Thereafter, a 30 percent evaluation is warranted. 38 C.F.R. § 4.116. Higher ratings are available for removal of the uterus and both ovaries. See Diagnostic Code 7617. A note indicates that entitlement to special monthly compensation under 38 C.F.R. § 3.350 should be reviewed. In a November 2015 rating decision, the RO granted the claim for entitlement to residuals of fibroid cysts, post hysterectomy and assigned a 30 percent rating. In a January 2016 Notice of Disagreement (NOD), the Veteran stated that her “ovaries float about and [her] doctor has a difficult time finding them.” She also stated that she was “told on several occasions that [she has] to have [her] ovaries removed.” Evidence indicates that the Veteran had a hysterectomy where her uterus was removed. Her ovaries were not removed. In a January 2017 correspondence, the Veteran reported that her uterus and cervix were removed during the hysterectomy, which caused her to suffer from symptoms such as vaginal dryness; menopause; severe mood swings; hot flashes and abnormal sweating. Based on the foregoing, the Board finds that the criteria for a rating in excess of 30 percent for residuals of fibroid cysts, status post hysterectomy, have not been met. In that regard, there is no dispute that the Veteran had her uterus and cervix removed during her hysterectomy, which warrants her currently assigned 30 percent rating. There is also no dispute that the Veteran’s ovaries were not removed. Although the Veteran has stated that she was told that her ovaries should be removed, they remain. As noted above, a higher rating (50 percent) is available if there is evidence that both ovaries were removed. There are no 45 or 90 percent ratings available for gynecological conditions, as the Veteran contends she is entitled to for her status post hysterectomy. There are no other Diagnostic Codes where she would be eligible for a higher rating. She is already in receipt of special monthly compensation for loss of a creative organ. REASONS FOR REMAND 1. Entitlement to service connection for skin lesions The Board finds that a remand is necessary to obtain a medical opinion from a dermatologist regarding the etiology of the Veteran’s skin legions. In November 2016, the Veteran developed a skin rash all over her body which she contends is related to her psychotropic medication, Wellbutrin, used to treat her service-connected depression. A December 2016 dermatological note indicates that it is unclear if the Wellbutrin caused the Veteran’s skin rash. A January 2017 follow dermatology note indicates that the Veteran’s lesions responded to treatment. After stopping treatment, the lesions resurfaced and the Veteran believed her new antidepressant medication contributed to the flare-up. A February 2017 VA dermatological treatment note indicates that the Veteran reported doing well since going back on Wellbutrin and has full confidence in the medication. The specialist noted that the Veteran did not think that the medication caused her skin rashes. She still gets mild flare-ups once in a while. The Veteran was afforded a VA skin diseases examination in June 2017 where she reported noticing a red rash on her right forearm which turned into white blotches and then permanent black spots. She reported that it spread to her other forearm and eventually her entire body. She stated that at one point, she thought the rash was connected to a new antidepressant, but even after she discontinued it, more lesions appeared. The examiner opined that it was less likely than not that the Veteran’s skin lesions were proximately due to or the result of the Veteran’s service-connected condition. The examiner explained that “[Pityriasis Lichenoid Chronica] PLC is an idiopathic acquired dermatosis that is classified as groups of erythematous scaly papulaes which can persist for months. It appears to be due to a hypersensitivity reaction to infectious agents such as EBV, adenovirus or parvovirus.” The examiner explained that although the lesions were suspected to be side effects of the Veteran’s antidepressant medication, per a January 2017 dermatology note, discontinuation of the suspected medication did not affect the rash at all. In an October 2017 Notice of Disagreement, the Veteran vehemently disagreed with the VA examiner’s findings. She questioned the examiner’s qualifications as an internist and not a dermatologist. She challenged the examiner’s conclusions that the Veteran’s PLC was due to hypersensitivity reactions to infectious agents. She contends that her dermatologist concluded her lesions were due to her various antidepressants – not just one. She said once she stopped all antidepressants, the lesions dissipated. In an addendum October 2017 medical opinion, the June 2017 VA examiner agreed that several of the medications the Veteran takes for her service-connected depression have been shown to cause a drug rash such as itching or hives; however, she did not see any literature that these medications cause PLC or PLEVA outside of antihistamines. She concluded that based on the foregoing, she cannot answer the question of etiology without resorting to mere speculation without a more definitive statement from a treating dermatologist. Based on the foregoing, the Board finds that a remand is necessary to obtain a medical opinion from a dermatologist. In that regard, the June 2017 VA examiner stated that she could not answer the question of etiology without resorting to mere speculation without more information from the Veteran’s treating dermatologist. Therefore, the question of etiology remains unanswered, but not necessarily unanswerable. A dermatologist may be able to better address the issue of the etiology of the Veteran’s skin lesions. Therefore, the Board remands the matter for a medical opinion from a dermatologist. 2. Entitlement to a compensable rating for abdominal scars is remanded. The Veteran was afforded a VA gynecological examination in October 2015 where the examiner noted that the Veteran had a scar related to her hysterectomy. The examiner noted that the scar was not painful and/or unstable and did not measure a total area of greater than 39 square centimeters. The examiner noted that the Veteran’s scar was linear; measured 25 centimeters in length and was well healed. However, in an October 2016 correspondence, the Veteran reported that her scar measures 14 inches in diameter; it itches; swells and is painful. She also reported that the Compensation examiner had difficulty measuring her scar. As there is a question of the severity of the Veteran’s scar, the Board finds that a remand is necessary to afford the Veteran a scars examination which assesses the current severity of her abdominal scar. 3. Entitlement to a rating in excess of 70 percent for major depressive disorder VA mental health treatment records from 2016 indicate that the Veteran reported symptoms of constant anger, rageful at times; sadness; sleep disturbances; alcohol abuse; avoidance of people She also reported that in the past she threw one of her co-workers to the floor. She endorsed past transient suicidal ideations, with no plan or intent. She reported taking care of her nephew for the past 10 years, but reported that he would be moving out of state with his mother soon, which saddened her. The Veteran was last afforded a VA mental disorders examination in March 2016 where she reported getting divorced due to her ex-husband wanting children and her inability to have any after her hysterectomy. She reported struggling with symptoms of depression for many years after her hysterectomy, which decreased when she began as a caretaker for her nephew. However, her depression symptoms increased after she discovered her nephew would be moving out of state. She reported symptoms of sadness daily, 1 to 2 times per day; low mood; loss of interest in normal activities; crying spells; change in appetite; sleep disturbance’ occasional psychomotor retardation; low energy; difficulty concentrating; feelings of hopelessness; and occasional recurrent thoughts of death. She denied any current suicidal ideations and no past suicide attempts. The examiner noted that the Veteran suffered from occupational and social impairment with deficiencies in most areas. On her November 2017 VA Form 9, the Veteran states that she has an explosive temper and cannot interact socially with others. She reports having frequent anxiety attacks. She states that there was a time when her antidepressants worked and she was able to socialize and enjoy life, but she stopped the antidepressants due to what she believed were side effects of skin lesions. Her symptoms of depression have returned and she reports having anxiety attacks while driving her car or at the super market. There is evidence that the Veteran’s symptoms may have worsened since her last examination. In that regard, it appears that symptoms that were previously under control may have returned since she stopped taking her antidepressants. See Weggenmann v. Brown, 5 Vet. App. 281 (1993); see also Snuffer v. Gober, 10 Vet. App. 400 (1997) (a Veteran is entitled to a new examination where there is evidence that the condition may have worsened since the last examination). Accordingly, the Board finds that a remand is appropriate, so that an accurate determination can be made as to the Veteran’s current level of symptomatology due to her major depressive disorder. Also, there is evidence that the Veteran receives regular treatment at a VA facility. Since the claims file is being returned it should be updated to include any recent VA treatment records that are not of record. See 38 C.F.R. § 3.159 (c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). 4. Entitlement to special monthly compensation (SMC) based on housebound status or due to the need for aid and attendance The Veteran contends that she is entitled to additional $4200 based on the guideline of special compensation. See June 2017 correspondence. Special monthly compensation is payable at the housebound rate where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). The United States Court of Appeals for Veterans’ Claims (Court) has held that the requirement that the claimant be “substantially confined” to his or her dwelling is met when the evidence establishes his or her inability to leave the house to earn an income. Howell v. Nicholson, 19 Vet. App. 540, 540 (2006). Further, the Court found that leaving one’s house for medical purposes cannot, by itself, serve as the basis for finding that one is not substantially confined for purposes of SMC based on housebound status benefits. Id. The Board finds that the issue of entitlement to SMC based on housebound status is inextricably intertwined with the matters it has remanded. In that regard, the Board has remanded the matters of entitlement to service connection for permanent lesions; entitlement to a rating in excess of 70 percent for major depressive disorder; and entitlement to a compensable rating for an abdominal scar for further development which may affect the Veteran’s total ratings. Once development for the remanded matters has been completed, the Agency of Original Jurisdiction (AOJ) should reexamine the issue of SMC based on housebound status. SMC based on aid and attendance, a higher level of compensation than that of SMC based on housebound status, is payable where a veteran, as the result of service-connected disability or disabilities, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, with 5/200 visual acuity or less, or is permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). The Veteran reported having a support network. In that regard, she stated that her sisters assist her everyday with tasks such as shopping; cleaning her house and taking her to doctor’s appointments. See January 2017 correspondence. She reported that she had to cease her medication because it was causing her to have an infection. While she has been unable to take her medication, she reports not being able to stay focused; the inability to drive because the movement caused anxiety attacks; memory loss; loss of motivation; lack of patience; and bouts of angry outbursts. A February 2017 dermatological note indicates that the Veteran had been doing well since returning to using Wellbutrin. She reports socializing with friends and being active in the church. She lives alone and drives. In a March 2017 correspondence, the Veteran stated that she needs assistance with some of her everyday living tasks. She also stated that she can no longer drive or work. In a June 2017 correspondence, the Veteran stated that she has no one to help her at home with everyday living and she sometimes has panic attacks. A June 2017 emergency department note indicates that the Veteran felt palpitations while she was driving and reported to the emergency room by herself. On her November 2017 VA Form 9, the Veteran reports needing assistance getting out of bed and getting dressed. She reports that she can no longer drive by herself. Her brother in law takes her to the store and pays her bills. She reports that she cannot go anywhere alone because she feels trapped and alone. An older woman helps her with household chores and cooking. The Board has remanded for a new VA examination which assesses the current severity of the Veteran’s major depressive disorder and for up to date VA treatment records. Therefore, the Board defers adjudication of the matter of SMC based on the need for aid and attendance until there is adequate evidence of the Veteran’s current status. The matter is REMANDED for the following action: 1. Obtain VA treatment records pertaining to the Veteran that date from December 2017 and associate them with the electronic claims folder. 2. Obtain a medical opinion from a dermatologist regarding the etiology of the Veteran’s skin lesions. A copy of the Veteran’s electronic claims folder, including a copy of this remand, must be made available to the specialist. The specialist is requested to address the following: Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s PLC is caused or aggravated by her service-connected depression, to include any medications taken to treat the depression. If aggravation is found, provide the baseline manifestations, and the increased manifestations due to the service-connected depression and/or the medication taken to treat the depression. The examiner is requested to address the Veteran’s contentions that all of the various types of antidepressants she has taken to treat her depression has caused/aggravated her PLC. See October 2017 Notice of Disagreement. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative, including noting whether there is additional information that could enable the examiner to provide the necessary opinion or whether the inability to provide the opinion was based on the limits of medical knowledge. The matter is being returned because the June 2017 VA examiner stated in an October 2017 addendum opinion that an opinion could not be rendered without further information from a treating dermatologist. A complete rationale for all conclusions reached should be provided. 3. Then, schedule the Veteran for a VA examination to assess the severity of her service-connected abdominal scar associated with residuals of fibroid cysts, status post hysterectomy. The examiner must review the claims file and must note that review in the report. All indicated tests should be performed, and all findings reported in detail. The examiner should note the length of the scar and whether or not the scar is superficial, unstable, deep, nonlinear, painful, exhibits visible or palpable tissue loss and either gross distortion or asymmetry of features. 4.Then, schedule the Veteran for a psychiatric examination in order to determine the severity of her service-connected major depressive disorder. (Continued on the next page)   5. Thereafter, readjudicate the claims, including the inextricably intertwined claims of SMC based on housebound status and/or the need for aid and attendance. If the benefits sought on appeal are not granted, the Veteran and her representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Baskerville