Citation Nr: 20072841 Decision Date: 11/12/20 Archive Date: 11/12/20 DOCKET NO. 15-14 456 DATE: November 12, 2020 ORDER Service connection for right lower extremity neuropathy is granted. Service connection for a dental disability is denied. An effective date of August 1, 2013, and no later, is warranted for the reduction of the 100 percent rating for service-connected laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, subject to the statutes and regulations governing the payment of monetary benefits. As of August 1, 2013, an evaluation in excess of 30 percent for service-connected laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy is denied. An effective date of August 1, 2013, for service connection for cis-platin renal toxicity, and no earlier, is granted, subject to the statutes and regulations governing the payment of monetary benefits. An effective date of August 1, 2013, for service connection for hypothyroidism, and no earlier, is granted, subject to the statutes and regulations governing the payment of monetary benefits. An initial evaluation in excess of 60 percent for cis-platin renal toxicity is denied. An initial evaluation in excess of 10 percent for hypothyroidism is denied. REMANDED The claim for service connection for sinusitis is remanded. FINDINGS OF FACT 1. The Veteran’s right lower extremity neuropathy is related to his treatment for laryngeal and tonsillar cancer. 2. The Veteran does not have a dental disability for VA compensation purposes. 3. Surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedures for laryngeal and tonsillar cancer ceased on January 18, 2013. 4. Residuals of laryngeal and tonsillar cancer treatment include hoarseness, sore throat and xerostomia, but not stenosis of the larynx, or organic aphonia. 5. As of August 1, 2013, the Veteran is shown to have had cis-platin renal toxicity. 6. As of August 1, 2013, the Veteran is shown to have hypothyroidism. 7. The Veteran’s cis-platin renal toxicity is not shown to have been productive of renal dysfunction with persistent edema and albuminuria with BUN at least 40 mg%; creatine at least 4 mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 8. The Veteran’s hypothyroidism requires the need for Synthroid taken on a daily basis, but it is not shown to be manifested by fatigability, constipation, and mental sluggishness. CONCLUSIONS OF LAW 1. The criteria for service connection for right lower extremity neuropathy have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. The criteria for service connection for a dental disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.381, 4.150. 3. An effective date of August 1, 2013, and no later, is warranted for reduction of the 100 percent evaluation for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy. 38 U.S.C. § 5112 (b)(6); 38 C.F.R. § 4.97, Diagnostic Codes 6516, 6819. 4. As of August 1, 2013, the criteria for an evaluation in excess of 30 percent for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.97, Diagnostic Codes 6516, 6519, 6520. 5. The criteria for an effective date of August 1, 2013, and no earlier, for service connection for cis-platin renal toxicity have been met. 38 U.S.C. §§ 5101 (a), 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400. 6. The criteria for an effective date of August 1, 2013, and no earlier, for service connection for hypothyroidism have been met. 38 U.S.C. §§ 5101 (a), 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400. 7. The criteria for an initial evaluation in excess of 60 percent rating for cis-platin renal toxicity are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.115a, 4.115b, Diagnostic Code 7535. 8. The criteria for an initial evaluation in excess of 10 percent rating for hypothyroidism are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.119, Diagnostic Code 7903. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1968 to August 1971 and from February 1975 to December 1975. In March 2019, the Board denied a claim for restoration of a 100 percent evaluation for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, and granted a claim for an initial increased rating for status post laryngeal malignant mass excision and tonsillectomy (previously evaluated as active cancer) to the extent that it determined that surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedures for laryngeal and tonsillar cancer ceased on September 21, 2012, and that the criteria for a 30 percent rating, and no more, were met as of April 1, 2013. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In April 2020, the Court issued an Order vacating the March 2019 Board decision and remanding the case for compliance with a Joint Motion for Remand (JMR). Service Connection The JMR shows that it was agreed that the Board’s March 2019 decision should have adjudicated claims for service connection for a right lower extremity neurological disorder, to include neuropathy, and a dental disorder, as residuals of the Veteran’s treatment for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Right lower extremity neurological disability. The Veteran’s medical records show that in July 2012, he underwent a laryngeal malignant mass excision and tonsillectomy. Thereafter, he underwent radiation (X-ray) and antineoplastic chemotherapy. His chemotherapy was interrupted due to neuropathy of his left leg after his first treatment, and after renal damage after the second treatment. In September 2012, he was hospitalized due to a creatinine elevation after his second chemotherapy treatment. Although the evidence is somewhat conflicting, it appears that his chemotherapy treatment ended no later than December 2012. The Veteran’s medical records show complaints of sciatica as early as August 2012, at which time he denied neuropathy in his feet, or any focal neurologic deficit. VA reports, dated in 2013, note decreased sensation on the anterior aspect of his right shin, with no other focal motor or sensory deficit appreciated. There was no relevant diagnosis. A VA hematology and oncology follow-up report, dated in December 2013, notes that the Veteran reported having bilateral lower extremity pain and tingling which had worsened since the completion of his chemotherapy and which was aggravated by cold weather. A report, dated in May 2014, notes chronic neuropathy of the feet, status post chemotherapy for tonsillar cancer, with a recommendation for use of gabapentin for peripheral neuropathy. It appears that the Veteran began using gabapentin in September 2014. A VA peripheral nerves DBQ, dated in August 2014, shows that the Veteran reported having pain that “comes and goes” that started with his chemotherapy. He stated that he has nerve pain in his right leg. This was described as sciatic-type pain. The Veteran stated that his right leg pain pre-dated his chemotherapy. He denied having neuropathy issues with his feet. He stated that he has had foot pain, but that this was definitely prior to his cancer diagnosis, and it has now resolved. The DBQ notes the following: There is a history of neuropathic symptoms of unclear significance and etiology in 2012. The Veteran has no stocking-glove neuropathy. He has moderate intermittent pain in his right lower extremity. Strength at the right knee and ankle was 5/5. There was no muscle atrophy. Reflexes at the right knee and ankle were 2+. See also August 2014 VA thyroid DBQ (same). A sensory examination of the right lower extremity was normal. There was non-anatomic distribution of symptoms. The Veteran reported sciatic pain in his right leg, with pain at the medial knee but intact sensation to light touch and vibration. Foot sensation and proprioception were intact. He had normal plantar sensation, and normal balance. Gait was normal. All nerves, to include the right sciatic nerve, were normal. The Veteran’s right leg sciatic type pain was stated to pre-date his chemotherapy. The Veteran has an area on burning pain on the inside of his knee that may be related to neuropathy from cancer treatment, but this is highly atypical. The examiner stated an etiological opinion could not be provided until EMG-NCV (electromyogram/nerve conduction velocity) testing was performed. The diagnosis was neuropathic symptoms of unclear significance and etiology. A VA EMG/NCV consultation report, dated in September 2014, shows that the impressions noted chronic neuropathy in the feet status post chemotherapy for tonsillar cancer, and no evidence of lumbosacral radiculopathy. A VA medical opinion, dated in January 2015, shows that the examiner concluded that the Veteran’s “lower extremity radiculopathy” was at least as likely as not caused by, or a result of, his chemotherapy; the right or left lower extremity was not specified. VA progress notes, dated in 2015 and 2016, note that the Veteran has “some neuropathy of the feet,” and continued use of gabapentin. There is a notation that he is “taking Neurontin for his neuropathy secondary to his prior chemotherapy.” The Board finds that service connection for right lower extremity neuropathy is warranted. In July 2012, the Veteran underwent a laryngeal malignant mass excision and tonsillectomy, with treatment that included antineoplastic chemotherapy. His right lower extremity complaints have been somewhat inconsistent, however, since 2013 he has been shown to have decreased sensation on the anterior aspect of his right shin, with apparently increased symptomatology in December 2013. Chronic neuropathy of the feet is noted as of at least May 2014. This was corroborated in a September 2014 VA EMG/NCV study. The January 2015 VA medical opinion shows that the examiner concluded that the Veteran’s “lower extremity radiculopathy” was at least as likely as not caused by, or a result of, his chemotherapy. The examiner did not specifically discuss neuropathy of the right lower extremity, however, an etiological opinion should be viewed in its full context, and not characterized solely by the medical professional’s choice of words. Acevedo v. Shinseki, 25 Vet. App. 286, 293-94 (2012). In this case, the examiner summarized the Veteran’s medical history, which included complaints of bilateral lower extremity pain and tingling. Therefore, the January 2015 VA medical opinion could reasonably be interpreted to include the right lower extremity. Following this opinion, VA progress notes continue to indicate that the Veteran has neuropathy of his bilateral feet. Accordingly, affording the Veteran the benefit of all doubt, the Board finds that the evidence is at least in equipoise, and that service connection for right lower extremity neuropathy is warranted. Of note, the Veteran is already service connected for peripheral neuropathy of the left lower extremity. The Board notes that the Veteran’s neurological symptoms in his wrists have been attributed to carpal tunnel syndrome (CTS), and that there is no competent evidence associating his CTS with his 2012 treatment for laryngeal malignant mass excision and tonsillectomy. Therefore, the issue of service connection for a neurological disorder of the upper extremities has not been raised by the evidence. Dental disability. The JMR shows that it was agreed that the Board should have adjudicated the issue of service connection for a dental disorder. It is asserted that the Veteran has a dental disorder that is related to his July 2012 surgery and subsequent X-ray and chemotherapy. Dental disabilities which may be awarded compensable disability ratings are now set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Rating activity should consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. 38 C.F.R. § 3.381 (b). For loss of the teeth, bone loss through trauma or disease, such as osteomyelitis, must be shown for compensable purposes. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by suitable prosthesis. Id. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease (pyorrhea) are not disabling conditions. See 38 C.F.R. § 3.381. VA progress notes show that beginning in October 2013, the Veteran was provided with sodium fluoride oral cream (toothpaste). In December 2013, the Veteran’s teeth were noted to be present, and grossly normal. In August 2014, the Veteran sought treatment, stating, “I need to get my teeth cleaned.” He was provided with dental prophylaxis care and topic fluoride varnish. The diagnosis was accretions on teeth. Treatment status was characterized as “maintenance.” In April 2015, he sought treatment, stating, “I need my teeth cleaned and I broke a tooth or lost a filling.” The reports note that he has very good oral hygiene, with very little plaque or calculus on the teeth, and that he is brushing, flossing and using tooth paste regularly. The August 2014 report notes moderate bone loss. The April 2015 report notes slight plaque and calculus, with a missing #12D restoration, and that the Veteran stated that his tooth is not sensitive, but that he notices pressure when food packs into area. His tooth was sensitive with scaling. In August 2015, it was noted that the Veteran still has dryness in his mouth. He was told to brush his teeth more frequently, avoid dry food, and drink water frequently. The Board finds that the claim must be denied. In April 2015, following his laryngeal malignant mass excision and tonsillectomy that was treated with X-ray and chemotherapy, the Veteran sought treatment for a broken tooth or a lost filling. There is no competent evidence associating this condition with his treatment for his laryngeal malignant mass excision and tonsillectomy. He also received routine dental treatment. There is no evidence to show that the Veteran has one of the dental disorders listed under 38 C.F.R. § 4.150, and there is therefore no basis for an award of compensation based on the Veteran’s claim. Given the foregoing, the evidence does not show that the Veteran sustained compensable “dental trauma” due to his VA treatment, or that he has a compensable dental disorder, and there is no basis for an award of compensation based on the Veteran’s claim. 2. Increased rating for service-connected laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, to include the issue of whether a reduction in the disability rating from 100 percent to 30 percent, effective April 1, 2013, was proper. In an October 2013 rating decision, the RO granted service connection for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, effective July 31, 2012. The RO evaluated this disability as 100 percent disabling until March 31, 2013, with a 10 percent rating assigned for status post laryngeal malignant mass excision and tonsillectomy (previously evaluated as active cancer) effective April 1, 2013. The RO stated, “Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination.” See 38 C.F.R. § 4.97, Diagnostic Code (DC) 6819. In March 2019, the Board determined that a rating of 30 percent was warranted as of April 1, 2013. The Veteran appealed to the Court, and in April 2020, the Court issued an Order vacating the March 2019 Board decision and remanding the case for compliance with a JMR. The JMR shows that it was agreed that, “The Board did not adequately explain why a later effective date for the discontinuance of the 100 percent rating for cancer under 38 C.F.R. § 4.97, Diagnostic Code (DC) 6819, was not warranted.” Effective date of reduction, 100 percent rating. The Board will therefor first analyze the issue of whether the Veteran is entitled to a later effective date for the reduction in his 100 percent rating, currently established as April 1, 2013. Under 38 C.F.R. § 4.97, Diagnostic Code (DC) 6819, a 100 percent rating is assignable for neoplasms, malignant, any specified part of respiratory system exclusive of skin growths. The note following DC 6819 states that a rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105 (e). If there has been no local reoccurrence or metastasis, rate on residuals. Notice is required only when there is a reduction in “compensation payments currently being made.” See 38 C.F.R. § 3.105 (e). In this case, the Veteran’s 100 percent rating compensation payments were not being made prior to the decrease in his rating, therefore notice was not required. Tatum v. Shinseki, 24 Vet. App. 139, 142-144 (2010). The Board is still required to considered whether medical care “constituted treatment” of the Veteran’s cancer within the meaning of DC 6819. Id. The Board finds that the correct effective date for the reduction of the Veteran’s 100 percent rating is August 1, 2013. VA progress notes contain multiple and somewhat conflicting notations on this issue. There are notations that the Veteran’s last radiation treatment was on September 21, 2012. See e.g., September 11, 2013, June 21, 2013 and December 20, 2013 otolaryngology notes. At least one report notes that his most recent radiation therapy and antineoplastic therapy treatments were in October 2012 (no day provided), and that the date of completion of treatment or anticipated date of completion was in October 2012 (no day provided). See VA orthopedic surgery examination report, dated September 16, 2013. Other VA reports indicate that the Veteran’s chemotherapy treatment ended in December 2012, with no day provided. See e.g., September 11, 2013 otolaryngology report. However, and of particular note, and as was noted in the JMR, a VA surgery outpatient note, dated January 18, 2013, shows that the Veteran had a PEG tube (percutaneous endoscopic gastrostomy tube) placed in July 2012, due to concerns with difficulty with feeding during chemotherapy and radiation therapy, and that he has been tolerating a general diet with daily flushing of his PEG tube, which was removed “by the bedside.” It does not appear that the removal of the Veteran’s PEG tube was a complicated procedure, or that anaesthesia was required. Nevertheless, the note to DC 6819 states that a rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. (emphasis added). The note is therefore worded broadly, and the removal of the Veteran’s PEG tube, which was placed in association with chemotherapy and radiation therapy, could reasonably be considered to be a “therapeutic procedure.” The Board therefore finds that the correct effective date for the reduction of the Veteran’s 100 percent rating is August 1, 2013 (the first day of the month following six months after discontinuance of his treatment on January 18, 2013). See 38 C.F.R. § 3.31. A reduction later than August 1, 2013 is not warranted under DC 6819. There is no evidence to show a recurrence of the Veteran’s laryngeal cancer, or that it metastasized. VA progress notes, dated in June 2013, state that the Veteran’s laboratory results are stable. It was noted, “His creatinine level remains a little elevated, but it is improved from the previous level.” A VA DBQ, dated in September 2013, shows that the examiner indicated that the Veteran has completed treatment for a benign or malignant neoplasm or metastases, and that he is he is in watchful waiting status. A December 2013 PET scan was negative for recurrent disease. An August 2014 thyroid DBQ notes that there was no benign or malignant neoplasm or metastases associated with his condition. In September 2016, the Veteran reported new symptoms that were worrisome for recurrent disease, however, an examination was unremarkable, and a CT scan of the neck was negative for recurrence. Accordingly, the Veteran’s cancer is not shown to have recurred. To the extent that the Veteran has had ongoing residual symptoms from his surgery, a continued 100 percent rating under DC 6819 is not warranted. The Board has determined that the cessation date of the Veteran’s surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure is January 18, 2013, and DC 6819 makes it clear that although a veteran may have residuals of cancer, residuals alone cannot serve as a basis for a 100 percent evaluation for that cancer. The rating schedule mandates that the residuals be rated under other diagnostic codes as of six months from the date upon which the cancer treatment ceased. Id. Increased initial evaluation, laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy. The next issue is whether an initial evaluation in excess of 30 percent for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy is warranted as of August 1, 2013. In March 2019, the Board increased the Veteran’s rating to 30 percent under DC 6516. Under DC 6516, a 30 percent rating is assigned for hoarseness with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. The 30 percent rating is the maximum rating allowed under DC 6516. A higher rating is not warranted under any other diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Under DC 6520, a 60 percent rating is warranted for larynx, stenosis of, including residuals of laryngeal trauma (unilateral or bilateral), with FEV-1 of 40- to 55-percent of predicted, with Flow-Volume-Loop compatible with upper airway obstruction. Overall, there are multiple complaints of a sore throat and xerostomia (dry mouth), as well as some neck pain. A September 2013 VA disability benefits questionnaire (DBQ) shows that the examiner indicated that the Veteran does not have laryngeal stenosis, and there is no evidence of laryngeal stenosis. The Veteran was subsequently noted to have some leukoplakic change of left posterior pharyngeal wall and hypertrophy of BOT (base of tongue) papilla on the right. See April 2017 VA progress note. However, there are no findings of laryngeal stenosis. Accordingly, an evaluation in excess of 30 percent is not warranted under DC 6520. There is no evidence of complete organic aphonia, which warrants a 60 percent rating where there is a consistent inability to speak above a whisper. DC 6519. See e.g., September 2013 VA DBQ (noting that the Veteran does not have complete organic aphonia); VA progress notes, dated in October 2014 (noting good vocal cord movement on phonation); July 2015 (noting moving vocal cords); April 2017 (noting that the Veteran’s vocal cords were within normal limits on examination, and mobile on phonation). Earlier effective dates, service connection, kidney and thyroid disabilities. The JMR states that the Veteran’s April 2015 appeal to the Board encompassed the issues of entitlement to earlier effective dates for the grant of separate ratings for the kidney and thyroid conditions, as well as higher ratings for those conditions, and that the Board should have adjudicated these issues. In July 2012, the Veteran underwent a laryngeal malignant mass excision and tonsillectomy. Thereafter, he underwent radiation (X-ray) and antineoplastic chemotherapy. In July 2012, the Veteran, who had service in Vietnam and who is therefore presumed to have been exposed to Agent Orange, filed a claim for service connection for cancer of the larynx. See Veteran’s claim (VA Form 21-526b), received in July 2012; see also 38 C.F.R. §§ 3.307, 3.309. In October 2013, the RO granted service connection for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, as secondary to herbicide exposure. In August 2014, the RO granted service connection for hypothyroidism, and cis-platin renal toxicity, with effective dates of January 8, 2014 for each disability, in each case the RO noted that date to be “the date of receipt of your claim for this condition.” The RO stated that the Veteran’s hypothyroidism, and cis-platin renal toxicity, were related to his service-connected laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy. See 38 C.F.R. § 3.310. Generally, the effective date of an award of a claim is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400 (b)(2). An application, formal or informal, which has been allowed or disallowed by the agency of original jurisdiction and the action having become final by the expiration of 1 year after the date of notice of the disallowance, or by denial on appellate review, whichever is the earlier. 38 C.F.R. § 3.160 (d). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). Any communication or action indicating an intent to apply for VA benefits from a claimant or representative may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155 (a). VA progress notes show that beginning in September 2012, the Veteran was noted to be undergoing chemotherapy with cis-platin, and radiation therapy daily (five days a week). His renal function appeared to have improved with extra fluids. He was on a highly nephrotoxic agent, and it was very likely he has some intrinsic kidney damage at baseline. There was a notation of a history of a kidney injury, likely residual to his laryngeal treatment, i.e., from both cis-platin and dehydration, “which continues today but is slightly worse.” The Veteran was noted to be hypothyroid, and to be using Levothyroxine. In May 2013, the Veteran was noted to be hypothyroid, and to be using Synthroid, which was increased. In September 2013, he was noted to have “significant hypothyroidism.” In December 2013, the Veteran was noted to have hypothyroidism, with a notation of thyroiditis, and a history of renal damage related to chemotherapy that resulted in the cessation of chemotherapy in December 2012. The Board finds that effective dates of August 1, 2013, are warranted for service connection for the Veteran’s hypothyroidism, and cis-platin renal toxicity. The Veteran is shown to have had both these conditions as of at least September 2012, during treatment for laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy. Accordingly, the criteria for effective date of August 1, 2013, for service connection for hypothyroidism, and cis-platin renal toxicity, have been met. To this extent, the claims are granted. Effective dates prior to August 1, 2013 are not warranted. In this decision, supra, the Board has determined that the correct effective date for the cessation of the specified treatment at DC 6819 for the Veteran’s laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy is August 1, 2013. The Veteran will therefore have been in receipt of a 100 percent evaluation for treatment of his cancer until August 1, 2013. As such, payment of compensation for these thyroid and kidney disorders, which are residuals of his laryngeal cancer, is not appropriate until after that date. 3. Increased initial ratings. The next issue is whether, as of August 1, 2013, the Veteran is shown to have met the criteria for an evaluation in excess of 60 percent for cis-platin toxicity, or an evaluation in excess of 10 percent for hypothyroidism. Cis-platin renal toxicity. The Veteran’s cis-platin renal toxicity has been evaluated as 60 percent disabling under 38 C.F.R. § 4.115b, DC 7535. Under 38 C.F.R. § 4.115b, DC 7535, Toxic nephropathy is to be rated as renal dysfunction. Under 38 C.F.R. § 4.115a, Renal dysfunction, an 80 percent rating is warranted for: Renal dysfunction when it results in persistent edema and albuminuria with BUN 40 to 80 mg%; or, creatine 4 to 8 mg%, or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The relevant historical findings show that a VA progress notes, dated in May 2013, indicated that the Veteran was counseled to lose weight and to exercise. 38 C.F.R. § 4.1. During the time period in issue, the medical evidence shows that in September 2013, the Veteran was noted to have suffered a kidney injury likely from both cis-platin and dehydration “which continues today but is slightly worse.” His creatinine and BUN (blood urea nitrogen) levels have been slowly improving since completion of chemotherapy. The Veteran reported that his energy has been good. He otherwise had no other complaints and he denied any fevers, chills, chest pain, night sweats, shortness of breath, nausea, vomiting, changes in his bowel or urinary habits, or any new focal neurologic deficits. He denied weight loss. In December 2013, the Veteran reported that his energy was good. He denied interference with eating or weight loss, nausea, vomiting, changes in his bowel or urinary habits or any new focal neurological deficits. His creatine level is coming back down. He denied weight loss. A May 2014 report notes that his BUN level was within normal limits. A VA DBQ, dated in September 2013, notes that the Veteran weighed 156 pounds. A VA kidney DBQ, dated in August 2014, notes that Veteran had normal renal function but after initial cis-platin therapy he developed an increase in creatinine to the mid to high 2.00s. This resolved to a great extent when he completed therapy, however his still has a small increase in baseline creatinine. His last two measurements have been 1.47 (1.4 is the upper level of normal). His creatinine level was to be re-checked next week during his hematology-oncology visit, so it was not ordered. The Veteran’s treatment plan does not include taking continuous medication for the diagnosed condition. The Veteran has renal dysfunction. There are no signs or symptoms due to renal dysfunction. He does not require dialysis. The renal tubular disorder is not symptomatic. He does not have frequent attacks of colic with infection (pyonephrosis). The Veteran has never had, and does not now have, kidney, ureteral or bladder calculi (urolithiasis). There is no history of history of recurrent symptomatic urinary tract or kidney infections, and no associated benign or malignant neoplasm or metastases. BUN level was normal. His EGFR (estimate glomerular filtration rate) was abnormal. The diagnosis was cis-platin renal toxicity, with a date of diagnosis of August 2012. The Veteran’s kidney condition does not impact his ability to work. VA progress notes, dated beginning in 2015, show that the Veteran was counseled to lose weight. The Veteran’s weight was noted to be stable. He denied weight loss “or any other symptoms.” See e.g., VA progress notes, dated in May and August of 2015, February 2016. An August 2016 report notes that a physical examination and laboratory findings were “reassuring.” Cr [creatine] was 1.63 today “which is stable.” In February 2017, the Veteran reported that his energy is “quite good,” and that his appetite and weight are stable. A December 2016 report notes a history of chronic renal insufficiency after chemotherapy, and that the Veteran’s GFR (glomerular filtration rate) has been stable “around 40s.” The Board finds that the claim must be denied. Although the Veteran has residuals of laryngeal cancer, a rating in excess of 60 percent is not warranted. There is no evidence to show that the Veteran has renal dysfunction resulting in persistent edema and albuminuria with BUN 40 to 80 mg%; or, creatine 4 to 8 mg%, and the evidence is insufficient to show that his symptoms are productive of generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Overall, his weight has tended to range between 156 and 170 pounds, and he has been counseled to lose weight and to exercise. Accordingly, as the evidence is insufficient to show that the criteria for an evaluation in excess of 60 percent have been met for the Veteran’s service-connected cis-platin renal toxicity at any time during the rating period on appeal, the Board concludes that his symptoms more closely approximate the criteria for the currently assigned rating of 60 percent. Hypothyroidism. The Veteran’s hypothyroidism has been evaluated as 10 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7903. Under DC 7903, a 10 percent rating is warranted for hypothyroidism with fatigability, or; continuous medication required for control. A 30 percent is warranted for hypothyroidism with fatigability, constipation, and mental sluggishness. Id. Under DC 7903, for a 30 percent rating, all of the listed symptoms must be shown. Melson v. Derwinski, 1 Vet. App. 334 (1991). VA progress notes show that in September 2013, the Veteran reported that his energy has been good. He otherwise had no other complaints and denies any fevers, chills, chest pain, night sweats, shortness of breath, nausea, vomiting, changes in his bowel or urinary habits or any new focal neurologic deficits. The report states that he has healed well. Laboratory results showed significant hypothyroidism and his Synthroid was increased to 175 mcg. His weight was 159.5 pounds. In December 2013, he reported that his energy was good. He denied changes in his bowel or urinary habits. His last TSH (thyroid stimulating hormone level) was within normal limits. In May 2014, and April 2015, his TSH was within normal limits. A VA thyroid DBQ, dated in August 2014, shows that the Veteran was noted to be on replacement hormone with excellent serum TSH response. The examiner stated that the Veteran had no symptoms associated with thyroid or hypothyroid treatment at this time. The examiner indicated that the Veteran does not have any residual endocrine dysfunction following his treatment. There are no findings, signs or symptoms attributable to a hyperthyroid condition or a hyperparathyroid condition. The Veteran does not have symptoms due to pressure on adjacent organs such as the trachea, larynx, or esophagus attributable to a thyroid condition. The Veteran takes Levothyroxine daily. On examination, the neck had no palpable thyroid enlargement or nodules. There was disfigurement of the neck due to enlargement of the thyroid gland. There was no benign or malignant neoplasm or metastases associated with his condition. The Veteran’s thyroid or parathyroid condition does not impact his ability to work. Thereafter, VA progress notes show use of Levothyroxine once a day. In August 2016, a thyroid function test was normal. His TSH was 2.29. In May 2015 and December 2016, the Veteran denied anorexia, constipation, a change in bowel habits, weakness, difficulty with gait, gait disturbance, strength, or balance, lightheadedness, or alteration of special senses. The Board finds that the claim must be denied. Although the Veteran has residuals of laryngeal and tonsillar cancer, an evaluation in excess of 10 percent is not warranted. The evidence is insufficient to show that the Veteran has fatigability, constipation, and mental sluggishness. Overall, his weight has tended to range between 156 and 170 pounds, and he has been counseled to lose weight and to exercise. Accordingly, as the evidence is insufficient to show that the criteria for an evaluation in excess of 10 percent have been met for the Veteran’s service-connected hypothyroidism at any time during the rating period on appeal, the Board concludes that his symptoms more closely approximate the criteria for the currently assigned rating of 10 percent. REASONS FOR REMAND The claim for service connection for sinusitis is remanded. The JMR shows that it was agreed that the Board should have adjudicated the issue of service connection for sinusitis. The Veteran asserts that service connection for sinusitis is warranted as secondary to the treatment for a laryngeal malignant mass excision and tonsillectomy in July 2012, followed by radiation and chemotherapy. VA progress notes, dated as early as 2000, note sinus symptoms, to include a May 2012 CT scan which notes left maxillary sinus disease, but that the findings may represent acute on chronic sinusitis however, a malignancy, although less likely, cannot be ruled out. In July 2012, the Veteran underwent a laryngeal malignant mass excision and tonsillectomy, followed by radiation and chemotherapy. Thereafter, a September 2012 report notes that the Veteran was asymptomatic “other than on-and-off headaches, possibly related to sinus damage from H/N (head and neck) radiation.” There was also a notation of possible radiation damage “to tissues and sinuses, which would correlate with the blood in his nasal secretions.” A September 2013 VA DBQ notes pansinusitis and near-constant sinusitis. Although the Veteran was afforded a VA sinus examination in September 2013, an etiological opinion was not obtained. On remand, the Veteran should be afforded an examination, to include an etiological opinion. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an examination of his sinuses to ascertain the etiology of any sinusitis. The examiner must be notified that service connection is currently in effect for: laryngeal and tonsillar cancer status post laryngeal mass excision and tonsillectomy, and that the Veteran is asserting that he has sinusitis as a result of his treatment for that condition that included X-ray radiation and chemotherapy. After review of the record, the examiner should address the following questions: a) Is it at least as likely as not (i.e., a likelihood of 50 percent or greater) that any sinusitis was caused by the Veteran’s treatment for his 2012 treatment for laryngeal and tonsillar cancer? Why or why not? b) Is it at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran’s sinusitis was aggravated (made worse) by his 2012 treatment for laryngeal and tonsillar cancer? Why or why not? If aggravation is found, the examiner should identify a baseline level of severity of the sinusitis by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the sleep apnea. If such cannot be done, it should be explained why. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S.E., 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.