Citation Nr: 20039907 Decision Date: 06/11/20 Archive Date: 06/11/20 DOCKET NO. 19-09 020 DATE: June 11, 2020 ORDER Entitlement to an initial disability rating of 30 percent, but no higher, for service-connected sarcoidosis from September 11, 2008 to November 19, 2018 is granted. FINDING OF FACT From September 11, 2008 to November 19, 2018, the Veteran’s service-connected sarcoidosis was manifested by pulmonary involvement with persistent symptoms that, as likely as not, required chronic low dose or intermittent corticosteroids. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran’s favor, the criteria for an initial disability rating of 30 percent for service-connected sarcoidosis between September 11, 2008 and November 19, 2018 are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.97, Diagnostic Codes 6600, 6846. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1971 to October 1973. This case is before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In the June 2015 rating decision, the RO granted service connection for sarcoidosis and assigned an initial noncompensable disability rating from September 11, 2008. In February 2016, VA received the Veteran’s timely NOD with the initial noncompensable disability rating assigned for the service-connected sarcoidosis. In December 2018, the RO issued a Statement of the Case. In February 2019, VA received the Veteran’s timely VA Form 9 appeal to the Board. During the pendency of the appeal, the RO issued a December 2018 rating decision that assigned a 100 percent rating for the service-connected sarcoidosis from November 19, 2018, but, continued the initial compensable rating prior to November 19, 2018. As the assignment of a 100 percent rating effective from November 19, 2018 is a complete grant of benefits sought on appeal as of that date, but not earlier, the Board’s analysis with respect to this claim for an initial compensable disability for the service-connected sarcoidosis is limited to the period from September 11, 2008 to November 19, 2018. 1. Entitlement to an initial compensable rating for service-connected sarcoidosis prior to November 19, 2018. The Veteran contends that an initial compensable rating is warranted for his service-connected sarcoidosis prior to November 19, 2018. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Staged ratings must be considered and are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran’s service-connected sarcoidosis is rated as 100 percent disabling from November 19, 2018 and noncompensable between September 11, 2008 and November 19, 2018 under 38 C.F.R. § 4.97, Diagnostic Code 6846. Under Diagnostic Code 6846, sarcoidosis with chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment is rated 0 percent disabling. Sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids is rated 30 percent disabling. Sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control is rated 60 percent disabling. Sarcoidosis with cor pulmonale, or; cardiac involvement with congestive heart failure, or; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment, is rated 100 percent disabling. 38 C.F.R. § 4.97, Diagnostic Code 6846. Alternatively, sarcoidosis may be rated pursuant to Diagnostic Code 6600 under the rating criteria for chronic bronchitis. C.F.R. § 4.97, Diagnostic Code 6846 (“or rate active disease or residuals as chronic bronchitis (DC 6600) and extra-pulmonary involvement under specific body system involved”). Diagnostic Code 6600 provides ratings for chronic bronchitis based on the results of pulmonary function tests (PFTs). Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 66- to 80-percent predicted, is rated 10 percent disabling. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56- to 70- percent or; DLCO (SB) of 56- to 65-percent predicted, is rated 30 percent disabling. 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), is rated 60 percent disabling. 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; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97, Diagnostic Code 6600. The Veteran has competently testified to symptoms of cough, fatigue, shortness of breath, loss of appetite, weight loss, fever, night sweats, and sleep problems as a result of “flare-ups” of his sarcoidosis occurring throughout the appellate period. See February 2016 NOD. The Veteran also suffers from cataracts and autoimmune hepatitis. During the pendency of the appeal, service connection was established for cataracts as secondary to the service-connected sarcoidosis. See May 2016 Board decision. However, the Board denied service connection for the Veteran’s autoimmune hepatitis as secondary to the sarcoidosis. See June 2017 Board decision. The medical evidence shows that the Veteran was originally diagnosed with sarcoidosis in 1981 and was treated with high doses of prednisone. See Dr. L., September 1981 discharge note. However, by October 2008, the Veteran’s medical records characterize the sarcoidosis as “in remission.” Dr. K., follow-up visit report dated October 1, 2008. The Veteran’s medical records reflect that many of his reported symptoms for sarcoidosis are also potentially attributable to his autoimmune hepatitis, although the record is not entirely clear on that point. See gastrointestinal consult dated June 10, 2008. The Veteran has more recently taken prednisone, characterized by Dr. K. as “low dose,” for the hepatitis. See id. A private medical opinion from July 2010 also describes the Veteran’s sarcoidosis as in remission. See Dr. J., July 2010 private medical opinion. Nevertheless, the July 2010 opinion notes the Veteran’s reports of continuing symptoms of fever, chills, weight loss, and shortness of breath. See id. There is no medical evidence of record regarding the sarcoidosis between July 2010 and April 2015. The Veteran received an initial VA examination for his sarcoidosis in April 2015. Based on the October 2008 treatment note, the VA examiner concluded that the Veteran’s sarcoidosis was in remission. Additionally, he noted that the Veteran reported no current use of corticosteroids, inhalers, oral bronchodilators, or outpatient oxygen therapy to treat a breathing problem. A chest x-ray taken at the time of the VA examination revealed “streaky increased markings in the right upper lobe which could be chronic,” but provided no conclusion regarding the markings because of the unavailability of prior studies. The VA examiner recommended a one-year follow-up study; however, a follow-up study was never performed. During the VA examination, the Veteran reported constant shortness of breath. No pulmonary function testing (PFT) or exercise capacity testing was performed. There are no additional treatment records or examination reports of record for the sarcoidosis until November 2018. In November 2018, the Veteran received a new VA examination for his sarcoidosis. The VA examiner provided a diagnosis of sarcoidosis. During the VA examination, the Veteran testified to daily symptoms of chest pain, shortness of breath, chronic cough with sputum, and night sweats and chills. The Veteran reported no current treatment with corticosteroids, inhalers, oral bronchodilators, antibiotics, or outpatient oxygen therapy. Notwithstanding, based on x-ray evidence, the VA examiner noted the following findings, signs, and symptoms attributable to sarcoidosis: persistent symptoms of shortness of breath, chest pain, fever occurring 2 to 3 times per week, and daily night sweats; chronic hilar adenopathy; and, pulmonary involvement. However, she did not characterize the sarcoidosis as a progressive pulmonary disease. The VA examiner classified the sarcoidosis as “stage 2: bihilar lymphadenopathy and reticulonodular infiltrates.” Regarding the x-ray, the VA examiner described “mild scarring in right midlung with suggestion of adenopathy, which may be related to [the] patient’s history of sarcoidosis.” Finally, a PFT was performed. The PFT revealed the following findings: (1) pre-bronchodilator FVC of 58 percent predicted and post-bronchodilator FVC of 54 percent predicted; (2) pre-bronchodilator FEV-1 of 69 percent predicted and post- bronchodilator FEV-1 of 63 percent predicted; and (3) pre-bronchodilator FEV-1/FVC of 117 percent and post-bronchodilator FEV-1/FVC of 116 percent. The VA examiner noted that the FEV-1/FVC most accurately reflected the Veteran’s current level of disability. Based on foregoing, the Board concludes that a 30 percent disability rating under Diagnostic Code 6846 is warranted for the Veteran’s sarcoidosis between September 11, 2008 and November 19, 2018. In this regard, the record reflects that the Veteran’s sarcoidosis was found to be in remission after prescription of low dose prednisone, a corticosteroid, pursuant to treatment for nonservice-connected autoimmune hepatitis. Although the record shows that the prednisone was prescribed for treatment of the nonservice-connected autoimmune hepatitis, and not specifically for the sarcoidosis, it would be potentially prejudicial to conclude that the sarcoidosis did not also require the use of low dose corticosteroids simply because they were prescribed as treatment for a nonservice-connected disability. Notably, the fact that the Veteran was prescribed low dose corticosteroids for a nonservice-connected disability raises a question as to whether the Veteran would have required similar corticosteroid treatment for the sarcoidosis if such treatment had not been prescribed for the nonservice-connected autoimmune hepatitis. In other words, a question of doubt arises as to whether the Veteran’s sarcoidosis necessitated corticosteroid treatment at the same time as the corticosteroid treatment was provided for the non-service-connected hepatitis. Such reasonable doubt must be resolved in the Veteran’s favor. Therefore, the evidence is at least evenly balanced as to whether the prednisone treatment caused the Veteran’s sarcoidosis to go into remission; or, at the very least, whether the sarcoidosis necessitated such treatment. Accordingly, resolving reasonable doubt in the Veteran’s favor, the regimen of low dose prednisone had an ameliorative effect on the Veteran’s sarcoidosis. Furthermore, the Veteran has reported persistent symptomatology, including shortness of breath, cough, and fatigue, fever, and night sweats, during the appellate period. Accordingly, as the evidence shows that the Veteran’s sarcoidosis is manifested by low dose treatment with corticosteroids and pulmonary involvement with persistent symptoms, the criteria for a 30 percent rating under Diagnostic Code 6846 for the service-connected sarcoidosis are met between September 11, 2008 and November 19, 2018. However, a disability rating in excess of 30 percent between September 11, 2008 and November 19, 2018 is not warranted. The evidence does not show that the Veteran received high doses of corticosteroids, inhaled medications, an oral bronchodilator, antibiotics, or outpatient oxygen therapy at any point during the appeal. Moreover, although the Veteran contends that he has suffered weight loss due to his sarcoidosis during the period on appeal, there is no objective evidence of weight loss due to sarcoidosis contained in the Veteran’s medical records. The Veteran has not identified any records which document a significant change in weight. Additionally, the sarcoidosis was not shown to be a progressive pulmonary disease prior to November 19, 2018 and has not been manifested by cor pulmonale or congestive heart failure since the September 11, 2008 date of service connection. Indeed, even in the November 2018 VA examination report, the VA examiner did not describe the Veteran’s sarcoidosis as a progressive pulmonary disease. Furthermore, both the July 2010 private medical opinion and April 2015 VA examination report describe the Veteran’s sarcoidosis as in remission. Although the April 2015 VA examiner speculated that the Veteran’s chest x-rays may have indicated a chronic lung illness, no subsequent confirmatory studies are of record or have otherwise identified by the Veteran to show that the sarcoidosis was manifested by progressive pulmonary disease. (Continued on the next page)   Entitlement to a rating in excess of 30 percent under Diagnostic Code 6600 has also been considered. However, there is no PFT evidence of record during the appeal period until the November 2018 VA examination. Accordingly, there is no evidentiary basis to support a rating in excess of 30 percent under Diagnostic Code 6600 between September 11, 2008 and November 19, 2018. Finally, the Veteran is already in receipt of service connection for residuals of bilateral cataracts as a residual of treatment for sarcoidosis and has not identified other symptomatology not contemplated by Diagnostic Codes 6600 and 6846. Accordingly, the criteria for a 30 percent disability rating, but no higher, for service-connected sarcoidosis between September 11, 2008 and November 19, 2018 are more closely approximated. 38 C.F.R. § 4.97, Diagnostic Code 6846. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Law Clerk 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.