Citation Nr: 20005207
Decision Date: 01/22/20	Archive Date: 01/22/20

DOCKET NO. 12-21 311
DATE: January 22, 2020

REMANDED

Entitlement to an initial compensable evaluation for residuals of a tonsillectomy is remanded.

REASONS FOR REMAND

The Veteran had active duty service from January 1975 to November 1981. 

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2010 rating decision from a Regional Office (RO) of the Department of Veterans Affairs (VA).  In September 2016 and May 2018, the case was remanded for additional development and it now returns for appellate review.

Entitlement to an initial compensable evaluation for residuals of a tonsillectomy.

The Veteran contends that she is entitled to a compensable evaluation for residuals of a tonsillectomy.

Throughout the appeal period, the Veteran’s service-connected residuals of a tonsillectomy has been assigned a noncompensable (0 percent) rating by analogy pursuant to Diagnostic Code 6516, which outlines the rating criteria for chronic laryngitis, as VA rating criteria do not specifically include a provision for tonsillectomy residuals.  Pursuant to Diagnostic Code 6516, a 10 percent rating is warranted based on evidence of hoarseness, with inflammation of cords or mucous membranes, and a maximum 30 percent rating is warranted where there is evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97.  However, while the Veteran was afforded a VA examination in June 2019, to assess her residual disability from her in-service tonsillectomy, the examination report fails to provide any findings relevant to the aforementioned rating criteria.  Additionally, it appears as though the examiner reviewed the matter as a service connection claim, noting that there was no relationship between the Veteran’s tonsillectomy and sinusitis.  The Board notes that this is an increased rating claim.  As the Veteran’s medical treatment of record also fails to include any such relevant findings, there is no medical evidence upon which to rate this disability, and a remand is required to obtain a new, adequate VA examination. Substantial compliance with the Board’s May 2018 remand directives has not been accomplished.  See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order).

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The matter is REMANDED for the following action:

Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected tonsillectomy residuals.  The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  Specifically, the examiner should state whether the Veteran’s tonsillectomy residuals are productive of hoarseness, with inflammation of cords or mucous membranes; or hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy.  If no residuals are present, the examiner should indicate such.

 

 

C. CRAWFORD

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Brennae L. Brooks, Associate Counsel

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.