Citation Nr: 19190884 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 14-14 654 DATE: December 3, 2019 REMANDED Entitlement to a disability rating in excess of 30 percent for sarcoidosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1980 to August 1982. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In May 2018, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. 1. Entitlement to a disability rating in excess of 30 percent for sarcoidosis is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim for entitlement to a disability rating in excess of 30 percent for sarcoidosis. Under Diagnostic Code 6846, sarcoidosis is rated under either the rating criteria of Diagnostic Code 6846, the active disease or residuals of chronic bronchitis as set forth in Diagnostic Code 6600, or as extra-pulmonary involvement under the specific body system involved. 38 C.F.R. § 4.97, Diagnostic Code 6846. Under the specific criteria of Diagnostic Code 6846, a 60 percent rating will be assigned when the evidence of record shows sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. Lastly, a 100 percent rating will be assigned when the evidence of record shows sarcoidosis with cor pulmonale or cardiac involvement with congestive heart failure, or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 38 C.F.R. § 4.97, Diagnostic Code 6846. Sarcoidosis may alternatively be rated as chronic bronchitis under Diagnostic Code 6600. Ratings under Diagnostic Code 6600 fall within service-connected disabilities related to the Trachea and Bronchi and utilize different Pulmonary Function Tests in evaluating disabilities. 38 C.F.R. § 4.97. Those tests include Forced Expiratory Volume in one second (FEV-1), Forced Vital Capacity (FEV-1/FVC) and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)). Under Diagnostic Code 6600, a 60 percent rating is assigned for an FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is assigned for an FEV-1 less than 40 percent of predicted value; or FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or the requirement for outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6600. PFTs are required to rate respiratory conditions except in certain situations, such as when the PFTs are inconsistent with the other clinical evidence of record and the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Post-bronchodilator PFT studies should be used except when the results of pre-bronchodilator tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating a disability based on PFTs, post-bronchodilator results should be used unless such results are poorer than the pre-bronchodilator results, in which case the latter should be applied. 38 C.F.R. § 4.96 (d)(5). When there is a disparity between the results of different PFTs (FEV-1, FVC, etc.) so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(5). A December 2013 VA examination contains pre-bronchodilator pulmonary function test (PFT) results demonstrating impaired functioning but does not contain post-bronchodilator PFT results. The examiner noted that the degree of obstruction may be underestimated. The examination indicates that the Veteran’s respiratory disorder requires chronic low dose (maintenance) corticosteroids and daily inhalational bronchodilator therapy, with symptoms of shortness of breath, fatigue, night sweats, and weight loss. An April 2015 VA examination reflects the Veteran’s reported symptoms of shortness of breath and fatigue but indicates that sarcoidosis does not require corticosteroids or daily inhalational bronchodilator therapy. The examiner did not perform pulmonary function testing, noting that it was not applicable. In May 2018, the Board remanded this matter to the AOJ for a new examination to determine the current severity of the Veteran's respiratory disability, to include identifying associated symptoms and conducting pulmonary function studies, if appropriate. Subsequently, in a February 2019 VA examination, the Veteran was found to take albuterol every six hours for his sarcoidosis. The Veteran did not require the use or oral or parenteral corticosteroid medications, oral bronchodilators, or oxygen therapy. The Veteran was found to have persistent shortness of breath, pulmonary involvement and night sweats. This examination contains pre-bronchodilator pulmonary function test (PFT) results demonstrating impaired functioning but does not contain post-bronchodilator PFT results. The examiner stated that post-bronchodilator testing was not indicated in the Veteran's particular case but failed to provide a reason why. Therefore, the Board finds this examination to be inadequate for rating purposes because, per 38 C.F.R. § 4.96(d)(4), post-bronchodilator PFT studies should be used except when the results of pre-bronchodilator tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. VA’s statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, as the February 2019 VA examination has been found to be inadequate, the Board finds that a new VA examination, including pre and post-PFT results, must be obtained. The Veteran is notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655. The matters are REMANDED for the following action: 1. Request the Veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who provided treatment for the Veteran’s claimed disability. After securing the necessary releases, attempt to obtain all copies of pertinent treatment records identified by the Veteran that are not currently of record. At a minimum, obtain any outstanding VA treatment records. All attempts to obtain records must be documented in the claims folder 2. Then, schedule the Veteran for a VA examination to determine the extent and severity of the Veteran’s service-connected sarcoidosis. All indicated studies should be performed, to include a pre and post- pulmonary function testing (PFT). The examiner should review the results of all testing prior to completion of the examination report. The examiner should describe in detail all current manifestations of sarcoidosis. The results of a PFT are needed to determine: (a) the percentage of predicted FVC; (b) the percentage of predicted FEV-1; (c) FEV-1/FVC; and (d) the percentage of predicted DLCO (SB). If a DLCO (SB) (Diffusion Capacity of the Lung for Carbon Dioxide by the Single Breath Method) test is not obtainable, evaluation may be based on alternative criteria as long as the examiner states why the test would not be useful or valid. The examiner should also discuss whether there is: (a) pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids, (b) pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control; or (c) cor pulmonale; or cardiac involvement with congestive heart failure; or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. The supporting rationale for all opinions expressed must be provided. To the extent possible, the examiner should identify any symptoms and functional impairments due to sarcoidosis alone and discuss the effect of the Veteran’s sarcoidosis on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). A rationale should be provided for any opinion offered. Ziheng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.