Citation Nr: 21006016 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 14-27 070 DATE: February 3, 2021 ORDER 1. Prior to April 11, 2014, a rating in excess of 10 percent for lumbar spine intervertebral disc syndrome (IVDS) is denied. 2. Since April 11, 2014, a 20 percent rating, but no higher, for lumbar spine IVDS is granted. 3. A rating in excess of 30 percent for iatrogenic hypothyroidism is denied.   FINDINGS OF FACT 1. Prior to April 11, 2014, the Veteran’s back disability did not manifest by forward flexion limited to 60 degrees or less, combined range of motion of the thoracolumbar spine limited to 120 degrees or less, ankylosis, or incapacitating episodes of IVDS. 2. Since April 11, 2014, the Veteran’s back disability has manifested by combined thoracolumbar spine range of motion not greater than 120 degrees during repeated use over time and flareups, but not forward flexion limited to 30 degrees or less, ankylosis, or incapacitating episodes of IVDS. 3. During the appeal period, the Veteran’s iatrogenic hypothyroidism has not manifested as myxedema or resulted in muscular weakness, cold intolerance, weight gain, or residuals warranting a higher rating. CONCLUSIONS OF LAW 1. Prior to April 11, 2014, the criteria for a disability rating in excess of 10 percent for lumbar spine IVDS are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 2. Since April 11, 2014, the criteria for a 20 percent rating, but no higher, for lumbar spine IVDS are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5242. 3. The criteria for a rating in excess of 30 percent iatrogenic hypothyroidism are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3102, 4.3, 4.7, 4.10, 4.14, 4.25, 4.31, 4.88b, DCs 6354, 4.104, DCs 7010, 7101, 4.114, DC 7319, 4.119, DC 7903, 4.130. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1977 to February 1993. The case is on appeal from an October 2011 rating decision. In August 2017, the Veteran testified at a Board hearing. Thereafter, in an April 2018 decision, the Board denied an earlier effective date for a 30 percent rating for iatrogenic hypothyroidism and remanded service connection for posttraumatic stress disorder (PTSD) and the higher rating claims addressed herein. In a November 2020 rating decision, the RO granted service connection for PTSD with major depressive disorder (MDD) effective October 8, 2010. As the PTSD claim has been granted in full, it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Claims General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be 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. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 1. A rating in excess of 10 percent prior to September 17, 2019, and in excess of 20 percent thereafter, for lumbar spine IVDS. Specific Legal Criteria The Veteran’s low back disability is rated under DC 5242, which is rated according to The General Rating Formula for evaluating the spine. 38 C.F.R. § 4.71a. The General Rating Formula provides for a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Following the rating criteria, Note 1 states: evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate DC. Under the Formula for Rating IVDS Based on Incapacitating Episodes, a 10 percent rating is warranted with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months; a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. In addition, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is “factually ascertainable,” all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, “it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date.” Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Analysis The Veteran is seeking a higher rating for her service-connected back disability. During an August 2017 Board hearing, she reported experiencing constant back pain since service and wearing a back brace. She also reported taking prescription medication for pain. The Veteran was afforded an examination in regard to this claim in August 2011. She reported experiencing back symptoms of moderate pain, stiffness, spasms, and decreased motion. She also reported experiencing flareups resulting in pain, weakness, limitation of motion, and an inability to bend, stand for long periods, or lift heavy objects. The Veteran denied experiencing fatigue, paresthesias, numbness, weakness, and bowel or bladder problems. The examiner reported that the Veteran’s posture and gait were within normal limits. The examiner also reported range of motion on testing of forward flexion to 70 degrees, extension to 20 degrees, and right and left lateral flexion and right and left lateral rotation all to 25 degrees each. The examiner denied additional loss of range of motion on repetitive range of motion testing. The examiner also denied the presence of muscle spasms, tenderness, guarding, weakness, atrophy, ankylosis, and radiating pain on movement. The examiner found that the spine function was not additionally limited by pain, fatigue, weakness, and lack of endurance or incoordination on repetitive use. The Veteran’s treatment records show that, during the appeal period, she did not seek treatment for back symptoms after the August 2011 examination until April 2014. On April 11, 2014, she went to a VA emergency room for treatment of back pain. She denied experiencing an injury. The VA treatment provider gave her an injection of Toradol to treat the pain. Thereafter, the Veteran was afforded another examination for this claim on September 17, 2019 pursuant to the Board’s remand. The Veteran reported experiencing symptoms of constant back pain resulting an inability to bend, lift heavy objects, twist, turn while reaching, push, pull, and stand for prolonged periods of time. She also reported experiencing moderate to severe flareups every 5 or 6 days lasting a few hours to days. She further reported using a back brace and Ibuprofen, Tramadol, Cyclobenzaprine, Methocarbamol, and lidocaine to treat her symptoms. The examiner reported range of motion on testing of forward flexion to 60 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees each, and right and left lateral rotation to 20 degrees each, with pain on all ranges of motion and on palpation. The examiner also reported ranges of motion on 3 repetitions of testing of forward flexion to 55 degrees, extension to 10 degrees, right and left lateral flexion to 15 degrees each, and right and left lateral rotation to 20 degrees each. The examiner further reported estimated ranges of motion on repeated use over time and during flareups of forward flexion to 45 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees each, and right and left lateral rotation to 20 degrees each, or combined ranges of motion of 110 degrees. The examiner also found pain on passive motion and muscle spasms resulting in abnormal gait or spinal contour. The examiner further found that the Veteran experiences functional loss due to pain, fatigue, and lack of endurance. The examiner denied the presence of ankylosis, pain with weight-bearing, pain with nonweight-bearing, IVDS resulting in prescribed bed rest, guarding resulting in abnormal gait or spinal contour, and bowel and bladder problems. The examiner noted that the Veteran stated, in the absence of medication, she would have difficulty standing up or independently preparing meals and would be unable to perform daily activities such as cleaning the house. In a January 2020 rating decision, the RO granted a 20 percent rating for the Veteran’s lumbar spine and separate 20 percent ratings for right and left lower extremity radiculopathies, with such ratings effective September 17, 2019. The Board finds ratings in excess of 10 percent prior to April 11, 2014, and in excess of 20 percent thereafter, are not warranted. In this regard, prior to April 11, 2014, the evidence of record does not show forward flexion limited to 60 degrees or less, combined range of motion limited to 120 degrees or less, or episodes of IVDS resulting in prescribed bedrest. However, on April 11, 2014, the Veteran sought emergency care for back symptoms due to worsening symptoms. Prior to such date, she did not seek treatment for back symptoms subsequent to the August 2011 examination. Therefore, resolving reasonable doubt in the Veteran’s favor, April 11, 2014 is the first date indicating the more severe symptomatology shown during the September 2019 examination is factually ascertainable. See Swain, 27 Vet. App. at 224; DeLisio, 25 Vet. App. at 56. In addition, the evidence does not show that the Veteran has experienced forward flexion limited to 30 degrees or less, ankylosis, or IVDS with prescribed bedrest at any time during the period on appeal, including during flareups. The Veteran has consistently reported experiencing pain, weakness, limitation of motion, flareups, and the need for a back brace and medication during the appeal period. However, such impairment, even during flareups and with repetitive use over time, is contemplated by the ratings assigned for this disability during the period on appeal. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5242; DeLuca, 8 Vet. App. at 202. As outlined above, range of motion findings were estimated, as much as possible, taking into account the Veteran’s description of functional impairments due to repetitive use over time, flareups, pain, and other DeLuca factors. In this regard, the 20 percent rating has been granted based on the October 2019 examiner’s estimation of the Veteran’s ranges of motion on repetitive motion and during flareups. The Board has also considered the Veteran’s description of functional impairment of her spine in determining that no further increased ratings during the appeal period are warranted and that the ratings assigned most nearly approximate the disability. As noted above, the RO assigned separate ratings for right and left lower extremity radiculopathies in a January 2020 rating decision related to the lumbar spine disability. The evidence of record does not indicate the presence of any additional objective neurologic abnormalities for which a separate rating is warranted. In sum, the preponderance of the evidence shows that the Veteran’s back disability did not manifest in forward flexion limited to 60 degrees or less or combined range of motion limited to 120 degrees or less prior to April 11, 2014, and has not manifested in forward flexion limited to 30 degrees or less, ankylosis, or IVDS resulting in prescribed bedrest during the period on appeal. Therefore, the benefit of the doubt doctrine is not further applicable and while a 20 percent rating is warranted as of April 11, 2014, higher staged ratings are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. A rating in excess of 30 percent for iatrogenic hypothyroidism. Specific Legal Criteria The Veteran’s iatrogenic hypothyroidism is rated under DC 7903. Prior to December 10, 2017, under DC 7903, a 10 percent rating was assigned for hypothyroidism with fatigability, or where continuous medication is required for control; a 30 percent rating was assigned for hypothyroidism with fatigability, constipation, and mental sluggishness; a 60 percent rating was assigned for muscular weakness, mental disturbance, and weight gain; and a 100 percent rating was assigned for hypothyroidism with cold intolerance; muscular weakness; cardiovascular involvement; mental disturbance, to include dementia, slowing of thought, depression, bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, DC 7903. In addition, the Court of Appeals for Veterans Claims (Court) found that all the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 and resolved based on the evidence of record. The Court also stated that the rating criteria for DC 7903 are not successive. Tatum, 23 Vet. App. at 155. Thus, a claimant could potentially establish all the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. During the appeal period, effective December 10, 2017, the criteria to rate hypothyroidism changed. Under the new criteria for DC 7903, a 30 percent rating is assigned for hypothyroidism without myxedema for six months after the initial diagnosis. Thereafter, residuals of disease or medical treatment are rated under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, and mental disorders). A 100 percent rating is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). The 100 percent rating shall continue for six months beyond the date that an examining physician has determined crisis stabilization. Thereafter, the residual effects of hypothyroidism shall be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). The Board notes that, as the change in rating criteria did not specify that it was to have a retroactive effect, the pre-December 10, 2017 criteria and the revised criteria will both be considered and apply the criteria most favorable to the Veteran. However, an award is warranted under the revised criteria cannot be effective prior to December 10, 2017. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board also notes that, except for the pre-December 10, 2017 10 percent rating, the DC 7903 rating criteria are conjunctive, meaning that each element of the criteria is needed to meet the requirements for the specified evaluation. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007). Analysis The Veteran requested a higher rating for hypothyroidism in May 2011. During the August 2017 Board hearing, the Veteran stated that this condition results in symptoms of constipation, heart palpitations, memory issues, and being emotional and tired. She also stated that her blood pressure is constantly high. As the relevant rating criteria include the symptom of weight gain as well as consideration of rating the condition based on residuals, a review of the Veteran’s weight and blood pressure readings during the appeal period is necessary. She weighed 200 pounds with blood pressure 126/80 at separation from service in November 1992. VA treatment records show that she weighed 252 pounds with blood pressure 136/87 in July 2005 and weighed 215 pounds with blood pressure 142/88 in February 2010. The Veteran was afforded an examination in regard to this claim in August 2011. She reported symptoms of severe constipation, fatigability, sleepiness, emotional instability, depression, slowing of thought, and being cold when others are not cold. She also reported being diagnosed with chronic depression due to thyroid dysfunction. She further reported gaining 49 pounds in the past 2 years and taking medication daily. She denied experiencing side effects from treatment, tremor, poor memory, difficulty breathing or swallowing, and other heart or gastrointestinal symptoms. The examiner reported that the Veteran weighed 193 pounds and blood pressure readings of 125/92, 124/93, and 120/81. The examiner reported that the condition produces sequela of hypertension, tachycardia, and tremor, but found that it is quiescent. The Board notes that in this context, “quiescent” means “causing no trouble or symptoms.” https://www.merriam-webster.com/dictionary/quiescent. In August 2017, the Veteran submitted a thyroid disability benefits questionnaire (DBQ) completed by a private physician. The physician reported the presence of symptoms of residual endocrine dysfunction, heart palpitations, constipation, mental sluggishness, fatigue, and drowsiness. The physician also reported blood pressure 128/81 and denied the presence of exophthalmos and neck enlargement. The Veteran also submitted a letter from a VA psychiatrist in August 2017. The psychiatrist reported that the Veteran has PTSD and MDD that results in low energy, sadness, insomnia, and poor concentration and appetite. In May 2019, the Veteran was afforded a psychiatric examination. The examiner diagnosed her with PTSD and MDD. The examiner reported psychiatric symptoms including depressed mood, anxiety, sleep impairment, mild memory loss, and disturbances of motivation and mood. Thereafter, in September 2019, the Veteran was afforded a thyroid examination. She reported symptoms of episodic constipation, frequent need to use the bathroom, an inability to lose weight, lack of motivation, and indifference to social and physical activity. The examiner reported blood pressure 118/74 and thyroid symptoms of constipation and lack of energy when thyroid medication is not at an appropriate level. The examiner denied the presence of musculoskeletal, respiratory, cardiovascular, and gastrointestinal symptoms as well as eye involvement. The Veteran’s VA treatment records show her weight as 170 pounds and blood pressure 146/83 in March 2018 and her weight as 169 pounds and blood pressure 152/90 in September 2020. In a November 2020 rating decision, the RO granted service connection for PTSD with MDD and assigned a 10 percent rating from October 8, 2010 to May 17, 2018, and a 70 percent rating thereafter. The Board finds that a rating in excess of 30 percent is not warranted. The pre-December 10, 2017 rating criteria, being conjunctive, require the presence of muscular weakness and weight gain for a 60 percent rating and the presence of muscular weakness for a 100 percent rating. See 38 C.F.R. § 4.119, DC 7903; see also Camacho, 21 Vet. App. at 366. The evidence of record shows that the Veteran has lost weight during the appeal period, not gained weight. In addition, the Veteran has not reported, and the evidence does not show, the presence of muscular weakness due to hypothyroidism. The Veteran also has not satisfied the relevant criteria for a higher rating since December 10, 2017 under DC 7903 or for residuals of hypothyroidism under the applicable rating DCs. In this regard, she has not claimed and the evidence does not show that her hypothyroidism manifests as myxedema because it has not resulted in muscular weakness. See 38 C.F.R. § 4.119, DC 7903; see also Camacho, 21 Vet. App. at 366. In addition, the Board has considered whether rating the Veteran’s residual symptoms would result in a rating in excess of 30 percent since December 10, 2017. She has been found to experience sluggishness and indifference as symptoms of this condition. Under DC 6354 for chronic fatigue syndrome (CFS), ratings are provided for CFS consisting of debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms. 38 C.F.R. § 4.88(b), DC 6354. Under DC 6354, a 10 percent rating is assigned for signs and symptoms of CFS that wax and wane, but result in periods of incapacitation of at least one but less than two weeks total duration per year or symptoms are controlled by continuous medication; a 20 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least two but less than four weeks total duration per year; a 40 percent rating is warranted for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or; the signs and symptoms wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year; a 60 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or, signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year; and a 100 percent rating is assigned for signs and symptoms of CFS that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. Id. A note to DC 6354 provides that, for the purpose of rating CFS, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. Id. However, the Veteran has not claimed, and the evidence does not show, that the thyroid sluggishness or indifference symptoms results in periods of incapacitation of at least one week total duration per year or symptoms controlled by continuous use of medication. Id. In regard to medication use, the evidence shows that the Veteran takes medication to treat the thyroid condition, but not to treat the symptoms of sluggishness or indifference. Therefore, a compensable rating for such residuals under DC 6354 is not warranted. See 38 C.F.R. § 4.31. In addition, the August 2017 VA psychiatrist letter indicates that the Veteran experiences low energy, depressed mood, and sleep impairment due to a psychiatric disability. Such symptoms are compensated during at least part of the rating period based on the assigned ratings for PTSD with MDD resulting in reduced work efficiency. See 38 C.F.R. §§ 4.14, 4.130. The Board also notes that the Veteran’s hypertension has been linked to hypothyroidism. Hypertension is rated under DC 7101. Under DC 7101, a 10 percent rating is assigned for diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control; a 20 percent rating is assigned for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more; a 40 percent rating is assigned for diastolic pressure predominantly 120 or more and; a 60 percent rating is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. However, the evidence does not show elevated blood pressure readings warranting a compensable rating or a history of diastolic pressure predominantly 100 or more. See 38 C.F.R. §§ 4.31, 4.104, DC 7101. The Board has also considered rating the Veteran’s other claimed residuals of hypothyroidism under the applicable DCs. In this regard, the Veteran’s symptom of tachycardia is considered under DC 7010 for supraventricular arrhythmias, with a 10 percent rating assigned for permanent atrial fibrillation (lone atrial fibrillation) or one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor; and a 30 percent rating is assigned for tachycardia with more than four episodes per year documented by ECG or Holter monitor warrants a 30 percent disability rating. 38 C.F.R. § 4.104, DC 7010. Additionally, the Veteran’s reported constipation with episodes of frequently needing to use a bathroom are considered under DC 7319 for irritable colon syndrome, with a noncompensable rating assigned for mild irritable bowel syndrome with disturbances of bowel function with occasional episodes of abdominal distress; a 10 percent rating assigned for moderate irritable bowel syndrome with frequent episodes of bowel disturbance and abdominal distress; and a maximum schedular 30 percent rating assigned for severe irritable bowel syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. The Board notes that “severe” is “of a great degree.” www.merriam-webster.com/dictionary/severe. The Veteran’s tachycardia would not warrant a rating in excess of 10 percent because the evidence does not indicate the presence of four or more episodes per year documented by ECG or Holter monitor. 38 C.F.R. § 4.104, DC 7010. The Veteran’s reported symptoms under DC 7319 would not warrant a rating in excess of 10 percent because the evidence does not indicate a severe condition or near constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. Assigning separate 10 percent ratings under both DC 7010 and DC 7319 for residuals of hypothyroidism would not result in a combined rating in excess of the currently assigned 30 percent rating issued under the pre-December 10, 2017 hypothyroidism rating criteria. See 38 C.F.R. §§ 4.25, 4.118 DC 7903. Therefore, the 30 percent rating assigned based on the pre-December 10, 2017 hypothyroidism rating criteria remains in effect. In sum, the preponderance of the evidence shows that the Veteran’s iatrogenic hypothyroidism has not manifested as myxedema or resulted in muscular weakness, cold intolerance, weight gain, or residuals warranting a higher rating. Therefore, the benefit-of-the-doubt rule is not applicable and a higher rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Jimerfield 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.