Citation Nr: 18160857 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 12-06 842 DATE: December 28, 2018 ORDER Entitlement to an initial compensable rating for peripheral vascular disease of the bilateral lower extremities is denied. REMANDED Entitlement to a rating in excess of 10 percent for hypertension is remanded.   FINDINGS OF FACT For the entire appeal period, the Veteran’s peripheral vascular disease of the bilateral lower extremities did not result in claudication on walking more than 100 yards and diminished peripheral pulses or ankle/brachial index of 0.9 or less. CONCLUSIONS OF LAW The criteria for entitlement to an initial compensable rating for peripheral vascular disease of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.27, 4.104, DC 5199-7114. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1975 to September 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office. In December 2017, the Board remanded this matter for further development, more specifically, a VA examination, which was completed in February 2018. In addition to the Veteran’s bilateral peripheral vascular disease and hypertension, the VA examination also discusses the issue of surgical scars. The Board notes that it does not consider the issue of scars here, as it was separately rated and is not on appeal. In August 2018, the AOJ issued a Supplemental Statement of the Claim (SSOC). Additional documents were added to the Veteran’s claims file after the SSOC was issued. The Veteran filed his VA Form 9, Appeal to Board of Veterans’ Appeal in March 2012 and has not submitted a waiver. According to the Veteran’s claims file, medical records were submitted on the same date in August 2018 when the SSOC was issued. These medicals are listed on the SSOC among the evidence the AOJ reviewed. In addition, in October 2018, the Veteran submitted medical records relating to his right knee and aneurism, which issues are currently not before the Board. Finally, the Veteran submitted a lay statement to the AOJ and directly to the Board September 2018 and October 2018, respectively, and his representative an Informal Hearing Presentation also in October 2018. The Board finds that no prejudice will result to the Veteran with proceeding with a decision at this time. Entitlement to an initial compensable rating for peripheral vascular disease of the bilateral lower extremities. The Veteran contends that he should be granted an increased rating for peripheral vascular disease because of his condition; he cannot walk a city block without experiencing pain in his lower right extremities. A November 2009 rating decision granted the Veteran entitlement to service connection for peripheral vascular disease of the bilateral lower extremities with an evaluation of 0 percent, effective April 24, 2009. The Veteran is seeking a higher initial rating. A. Applicable Law Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities. 38 U.S.C. § 1155. Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition. 38 C.F.R. § 4.1. When rating the Veteran’s service-connected disability, the entire medical history must be reviewed. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board acknowledges that multiple distinct degrees of disability might be experienced which result in different compensation levels from the time the increased rating claim was filed until a final decision is made. Staged ratings apply to both initial and increased rating claims. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is a question as to which of the two disability evaluations is applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s disability was granted under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7199-7114. A hyphenated code is used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation. The Veteran’s disorder is not listed in the Rating Schedule. Accordingly, the AOJ assigned DC 7199-7114. See 38 C.F.R. § 4.27 (unlisted disabilities requiring rating by analogy are coded first the numbers of the most closely related body part and “99”). Under DC 7114, a 20 percent rating is warranted for arteriosclerosis obliterans resulting in claudication on walking more than 100 yards and diminished peripheral pulses or ankle/brachial index (ABI) of 0.9 or less. A 40 percent rating requires claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or an ABI of 0.7 or less. A 60 percent rating requires claudication on walking less than 25 yards on a level grade at 2 miles per hour, and either persistent coldness of the extremity or an ABI of 0.5 or less. A 100 percent rating is warranted for ischemic limb pain at rest, and either deep ischemic ulcers or an ABI of 0.4 or less. 38 C.F.R. § 4.104, DC 7114. The notes associated with DC 7114 are: (1): the ABI is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure (the normal index is 1.0 or greater); (2) evaluate residuals of aortic and large arterial bypass surgery or arterial graft as arteriosclerosis obliterans; and (3) these evaluations are for involvement of a single extremity; if more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25) using the bilateral factor (§ 4.26), if applicable. 38 C.F.R. § 4.104, DC 7114. B. Discussion The Veteran received treatment at the Ann Arbor, Michigan and Denver, Colorado VA Medical Centers. In the February 2018 VA examination report, the examiner noted that the Veteran underwent right popliteal artery aneurysm s/p right popliteal artery bypass surgery in August 2009, and left popliteal artery aneurysm s/p right popliteal artery bypass surgery followed by s/p viabatin stent in February 2009 and May 2011. The examiner also noted claudication on walking more than 100 yards in both legs. The examiner reported that bilateral ankle/brachial index tests were performed in January 2018, which were 0.98 on the right and 1.00 on the left. The Veteran reported that he gets cramps in his legs and said had to take a break when walking for long distances. The Veteran submitted a statement, according to which he told the examiner that he had claudication on walking between 25 and 100 yards, showed her the loss of hair on both of his feet and ankles, and told her that his feet and ankle are persistently cold to the touch. In addition, an August 2018 surgery follow-up reveals a normal toe/brachial index (TBI), 0.96 on the right and 0.98 on the left side, although ankle pressures were unobtainable due to calcification. During the same visit, the Veteran denied bilateral lower extremity claudication, rest pain, or ulcerations. According to a January 2018 vascular surgery diagnostic study report, the Veteran also denied bilateral lower extremity claudication, rest pain, or ulcerations. The healthcare provider noted bilateral lower extremities without edema, cyanosis, ulcerations, and palpable femoral pulses bilaterally, as well as a TBI of 1.07 on the right and 1.10 on the left side, measured during the previous examination. According to a September 2017 primary care nursing note, there was not an absence of a pedal pulse. During his July 2017 and January 2017 vascular surgery outpatient visits, although he had plantar fascitis (which had improved) and chronic knee pain, the Veteran denied claudication. He also had palpable femoral pulses bilaterally. During his January 2017 visit, his bilateral TBI was also normal, 1.07 on the right and 1.10 on the left, and his physicians noted that during a December 2015 examination, his bilateral ABI was also within normal limits. No absence of a pedal pulse and palpable femoral pulses bilaterally were also reported in July 2016 and June 2016, respectively. The June 2016 note also reveals that the Veteran was working at the time. The Veteran had a VA examination in December 2014. According to the examiner, during an April 2014 examination, the Veteran stated that he experienced claudication on walking between 25 and 100 yards. This was the Veteran’s own description of his condition. His branchial index was normal. The Veteran did not have any trophic changes due to his peripheral vascular disease. His February 2014 PV surgery outpatient note stated that the Veteran reported he was continuing to do well. He denied claudication completely that day. The Assessment section of that note stated that the Veteran was asymptomatic and his resting ABIs, including TBIs, were completely normal. Review of a December 2014 PV surgery outpatient note revealed that the Veteran denied claudication completely that day. The Assessment section of the note stated that the Veteran was asymptomatic and his resting ABIs, including TBIs, were completely normal. Although the Veteran complained of claudication on the day of the April 2014 exam, his brachial index was normal and the PV surgery medical notes clearly stated that he denied claudication. During his April 2014 VA examination, the Veteran also stated that he had constant dull pain in the posterior calf of both his right and left lower legs and behind both knees. He was taking Ibuprofen 800 mg. He was also taking Oxycodone before going to sleep to help with his pain as he stated his pain was also increased while trying to sleep. The pain was present at rest and activity. The pain was worsened with activity. He stated the pain was worse when he bent his knees and alleviated when he straightened out or extended his knees. He stated he was unable to walk long distances without experiencing increased leg pain and needed to sit down. He stated he got intermittent cold feeling in both feet. The Board notes that the Veteran’s statements regarding his symptoms have been inconsistent. He reported, uring his February 2018 and April 2014 VA examinations that he had bilateral claudication on walking more than 100 yards (requirement for a 20 percent DC 7114 rating) and bilateral claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour (requirement for a 40 percent DC 7114 rating). In contrast, the record shows several instances when he denied claudication. This does not appear to be a case where he was having the symptoms only intermittently. Overall, however, outside of the VA examinations he repeatedly denied claudication. Finally, the record has no evidence of diminished peripheral pulses or ABI of 0.9 or less (requirement for a 20 percent DC 7114 rating). Consequently, based on the evidence, including objective results of medical examinations and the Veteran’s own subjective, competent and contemporaneous statements made to his healthcare providers, the Veteran does not meet the criteria required under 38 C.F.R. § 4.104, DC 7114 for eligibility for an increased initial rating of 20 percent. Therefore, an initial rating more than 0 percent is not warranted, and the claim is denied.   REASONS FOR REMAND Entitlement to a rating in excess of 10 percent for hypertension. There has not been substantial compliance with the Board’s previous remand directives regarding the remaining issue. Another remand is therefore required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran contends that he should be granted an increased rating for hypertensive vascular disease (hypertension) because he is on multiple medications in order to treat his condition adequately, and he suffers from adverse side effects, including dizziness, excessive tiredness, and cold feet and hands. In addition, the record contains complaints of other side effects, including other symptoms, such as drowsiness, depression, and no sexual desire at all. See the November 2016 VA Form 646, Statement of Accredited Representative, the Veteran’s April 2014 statement, and the April 2014, September 2009 and July 2004 VA examination reports. In December 2017, the Board remanded this matter to the AOJ for a VA examination. The VA examination took place in February 2018. However, the VA examination report is inadequate, as the examiner did not clearly describe the nature and degree of any and all symptoms caused by the Veteran’s hypertension, to include the effects of his medication. In addition, the examiner did not provide a complete and detailed rationale in the opinion. Finally, the Board notes that since his March 2016 VA examination, the Veteran sustained a stroke secondary to his service-connected hypertension and peripheral vascular disease. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected hypertension. The examiner should clearly describe the nature and degree of any and all symptoms caused by the Veteran’s hypertension, to include the effects of his medication. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Robert Almosd, Associate Counsel