Citation Nr: 21008875 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 14-19 044 DATE: February 18, 2021 ORDER An initial rating of 60 percent, but no higher, for Graves’ disease prior to December 1, 2011, is granted. A rating in excess of 30 percent for Graves’ disease from December 1, 2011, to August 11, 2016, is denied. A rating in excess of 60 percent for Graves’ disease as of August 12, 2016, is denied. A total disability rating based on individual unemployability (TDIU) is moot. FINDINGS OF FACT 1. The weight of the competent and probative evidence prior to December 1, 2011, demonstrates that the residuals of Graves’ disease cause thyroid enlargement, tachycardia, increased pulse pressure and blood pressure, and requires continuous medication required for control, but does not cause symptoms of eye involvement, muscular weakness, loss of weight, or sympathetic nervous system. 2. The weight of the competent and probative evidence from December 1, 2011, to August 11, 2016, is against finding that the residuals of Graves’ disease cause symptoms of thyroid enlargement, eye involvement, muscular weakness, loss of weight, sympathetic nervous system, emotional instability, or gastrointestinal symptoms. 3. The weight of the competent and probative evidence as of August 12, 2016, is against finding that the residuals of Graves’ disease cause symptoms of eye involvement, muscular weakness, loss of weight, or sympathetic nervous system. 4. From December 19, 2009, a 100 percent combined evaluation for compensation is in effect based on multiple service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 60 percent, but no higher, for Graves’ disease prior to December 1, 2011, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, Diagnostic Code (DC) 7900. 2. The criteria for an initial rating in excess of 30 percent for Graves’ disease from December 1, 2011, to August 11, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, DC 7900. 3. The criteria for a rating in excess of 60 percent for Graves’ disease as of August 12, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, DC 7900. 4. The issue of entitlement to TDIU is moot. 38 U.S.C. §§ 5107, 7104; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.25, 20.104. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1992 to December 1999, May 2000 to August 2004, and November 2007 to December 2009. This case is before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In November 2017, the Veteran testified at a Board hearing. The transcript of the hearing has been associated with the record. The Veteran’s Law Judge who conducted the hearing has since retired; the Veteran was offered an opportunity for a new hearing, but no interest in a new hearing has been expressed. The Board remanded this case for further development in August 2018 and September 2020. As the requested development has been completed, no further action to ensure compliance with the remand directives is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating 1. Graves’ disease. The Veteran contends she is entitled to a 100 percent disability rating for her Graves’ disease after her final separation in December 2009 because she felt her Graves’ disease was not under control while in service and upon separation. She reports losing weight, difficulty doing tasks such as hammering, loss of muscle mass and strength, dyspnea while lying down, diarrhea, voiding urgency, insomnia, heart failure, trembling, and abnormal eye-movement. 11/14/2017, Hearing Transcript. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, VA will assign the higher evaluation if the disability picture more nearly approximates the criteria required for that rating. Otherwise, it will assign the lower rating. 38 C.F.R. § 4.7. VA resolves any reasonable doubt regarding the degree of disability in favor of the Veteran. 38 C.F.R. § 4.3. In the case of an initial rating, the entire evidentiary record from the time of a veteran’s claim for service connection to the present is of importance in determining the proper evaluation of the disability. Fenderson v. West, 12 Vet. App. 119 (1999). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before she filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the rating period on appeal, the Board can assign different or “staged” ratings for such different periods. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Effective December 10, 2017, VA revised 38 C.F.R. § 4.119. These revisions apply to all claims filed on or after December 10, 2017. VA is to consider claims filed before and pending on December 10, 2017, under both the old and new rating criteria and will apply whatever criteria are more favorable to the Veteran. 82 Fed. Reg. 50802. Under DC 7900 prior to December 10, 2017, a 100 percent disability rating was warranted for thyroid enlargement, tachycardia (more than 100 beats per minute (BPM)), eye involvement, muscular weakness, loss of weight, and sympathetic nervous system, cardiovascular, or gastrointestinal symptoms. A 60 percent disability rating was warranted for emotional instability, tachycardia, fatigability, and increased pulse pressure or blood pressure. A 30 percent rating was warranted for tachycardia, tremor, and increased pulse pressure or blood pressure. A 10 percent evaluation was warranted for tachycardia, which may be intermittent, and tremor, or; continuous medication required for control. If a heart disease is the predominant finding, then the disease would be evaluated as hyperthyroid heart disease (DC 7008) if doing so would result in a higher evaluation than using the criteria above. If ophthalmopathy is the sole finding, then the disease would be evaluated as field vision, impairment of (DC 6080); diplopia (DC 6090); or impairment of central visual acuity (DC 6061-6079). See 38 C.F.R. § 4.119 (2017), DC 7900. Under DC 7900 as of December 10, 2017, a 30 percent disability rating is warranted for six months after initial diagnosis; thereafter, residuals of the disease or complications of medical treatment are rated within the appropriate diagnostic codes within the appropriate body system. If a hyperthyroid cardiovascular or cardiac disease is present, a separate evaluation is warranted under DC 7008 (hyperthyroid heart disease), which allows for a rating under the appropriate cardiovascular diagnostic code in 38 C.F.R. § 4.104. Residuals of Graves’ disease affecting the eyes also warrant a separate evaluation: diplopia (DC 6090); impairment of central visual acuity (DCs 6061-6066); or the most appropriate diagnostic code in section 4.79. See 38 C.F.R. § 4.119, DC 7900. In evaluating a disability, the current examination reports considering the whole recorded history are evaluated to ensure that the current rating accurately reflects the severity of the disorder. The medical, as well as industrial history, is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Veterans are competent to report observable symptoms in the realm of their personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information, including lay and medical evidence of record, in a case before the Secretary concerning benefits under laws the Secretary administers. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). The higher evaluation will be assigned when two disability evaluations are potentially applicable, and the disability picture more nearly approximates the criteria for the higher rating. 3 8 C.F.R. § 4.7. VA has an independent obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes benefits. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008). The Veteran’s Graves’ disease is rated Under 38 C.F.R. § 4.119, DC 7900, with a 30 percent rating prior to August 12, 2016, and a 60 percent rating as of August 12, 2016. The Veteran also has two other service-connected disabilities caused by Graves’ disease—gastroesophageal reflux disease (GERD) under DC 7346 as of December 19, 2009, and severe mitral and tricuspid valve regurgitation with congestive heart failure associated with Graves’ disease under DC 7099-7005 as of October 20, 2011. For reference, DC 7005 warrants a 100 percent rating with documented coronary artery disease resulting in chronic congestive heart failure or workload of 3 METs or fewer resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year; or a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, DC 7005. Under DC 7346, the maximum 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss, and hematemesis, or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted when the evidence shows two or more symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, DC 7346. Under DC 7319, severe diarrhea, or alternating diarrhea and constipation, with constant abdominal distress warrants a 30 percent rating. Moderate, frequent episodes of bowel disturbance with abdominal distress warrant a 10 percent rating. Mild disturbances of bowel function with occasional episodes of abdominal distress are noncompensable. 38 C.F.R. § 4.114, DC 7319. The Veteran was diagnosed as having Graves’ disease while in service in 2008. A January 2006 medical evaluation during service a little over two years before the Graves’ disease diagnosis demonstrates the Veteran’s weight was 132 pounds. 01/13/2010, Medical Treatment Record (MTR)–Government Facility (GF). In August 2009, she was found not medically qualified for separation from service due to uncontrolled hyperthyroidism, a result of Graves’ disease. 04/21/2015, STR–Medical. A December 2009 treatment note, one week before her separation from service, notes the Veteran was experiencing diarrhea and urinary urgency. The physician assistant stated the Veteran had complete freedom from symptoms between episodes, including weight-related symptoms (the Veteran weighed 137.3 pounds), and the Veteran did not feel tired or poorly. See 10/07/2020, MTR–GF. Medical records associated with the file in October 2020 demonstrate the Veteran continued to suffer symptoms of diarrhea in January 2010 and in June 2010. Review of her symptoms in May 2010, June 2010, July 2010, and November 2010 are negative for palpitations or other cardiovascular symptoms, dyspnea or other pulmonary symptoms, feelings of weakness, hot flashes, flushing, or other endocrine or neurological symptoms. A review of her appearance and palpitations in 2010 demonstrated a normal neck, none of her lymph nodes were enlarged, respiration rhythm and depth were normal, respiratory movements were normal, lungs were clear to auscultation, heart rate and rhythm were normal, bowel sounds were normal, the abdomen was soft, abdominal muscle guarding or rigidity was not demonstrated, no abdominal tenderness, her appearance was normal, no evidence of recent weight loss, attitude and affect were normal, and her mood was euthymic, eyes were normal with pupils equal, round, reactive to light; however mild Graves ophthalmopathy was noted in July 2010. See 10/07/2020, MTR–GF. In a May 2010 VA examination, the Veteran did not report any other symptoms or conditions pertaining to cardiology, pulmonary, gastrointestinal, and neurology. Her weight was 135 pounds, pulse was 96 BPM, and she had no thyroid enlargement or abdomen issues. Her right eye movements were noted as abnormal; she has amblyopia with lateral deviation. The auscultation and a chest x-ray showed a normal heart size. The heart examination revealed normal pulse and heart sounds, and no evidence of congestive heart failure, cardiomegaly, or cor pulmonale. Examination of the extremities revealed no bilateral lower extremity edema and no evidence of hand tremor. The VA physician explained the effect of Graves’ disease (hyperthyroidism) on the claimant’s daily activity is a chronic cough, breast lump, fatigue, having to take medication, and insomnia. See 05/07/2010, C&P Exam. In a June 2010 VA examination, the Veteran reported her thyroid condition causes fatigability, sleepiness, tremor, poor memory, difficulty breathing, and difficulty swallowing. She described no emotional instability, depression, and slowing of thought. The Veteran claimed she lost 18 pounds in the last two years; her weight during this examination was 130 pounds. Her pulse was 102 BPM. Her thyroid condition has resulted in heart issues and gastrointestinal problems consisting of GERD. The examiner found no ocular signs of hyperthyroidism. The Veteran does have amblyopia of the right eye; however, the examiner explained amblyopia is unrelated to Graves’ disease, which, when untreated, can cause the unrelated eye disorder, exophthalmos. The examiner noted the thyroid condition causes hypertension and gastrointestinal disturbances with mild anemia. The Veteran’s bowel control impairment was attributed to GERD. See 07/09/2010, C&P Exam. An early December 2010 treatment note specifies the Veteran’s muscle bulk and signal were normal. 10/07/2020, MTR–GF. In late December 2010, a treatment note revealed the Veteran weighed 135.6 pounds, had a heart rate of 84 BPM in November 2010, had episodes of palpitations in the last few weeks, muscle weakness in the lower extremities, episodes of shakiness, decreased bowel frequency, no recurrence of diplopia, episodes of feeling warm and sweaty at times, thyroid gland appeared soft and about 2.5 times the normal size, but she had no chest pain or shortness of breath. 01/19/2011, MTR–GF. In January 2011, the Veteran became pregnant. 10/07/2020, MTR–GF. In a February 2011 VA examination, the Veteran described fatigability, sleepiness, tremors, emotional instability, depression, poor memory, difficulty breathing, and difficulty swallowing, but she also reported no slowing of thought, no problems in tolerating either hot or cold weather. Graves’ disease was found not to affect her body weight. The examiner found the Veteran did not have any heart or gastrointestinal complications resulting from her thyroid condition. The Veteran reported that she does not experience any overall functional impairment from this condition. The examiner observed no evidence of ocular signs of hyperthyroidism, lymphadenopathy, edema or pallor, jugular venous distension (JVD), or carotid bruits. On examination, the thyroid was palpable, soft, non-tender, not enlarged with no thyroid bruit. The heart sounds were normal with normal rate and regular rhythm. The examiner also detected no evidence of a hand tremor. See 02/23/2011, C&P Exam. A June 2011 treatment note indicates continuing issues with fecal incontinence. 05/26/2011, MTR–GF. An October 2011 treatment note contains pulmonary edema evidence, which increased the Veteran’s Burch-Wartofsky Point Scale (BWPS) from 15 to 30 in one week. 10/07/2020, MTR–GF. The Veteran’s chronic hypertension and Graves’ disease resulted in complications while giving birth in October 2011. The record demonstrates an onset of dyspnea and hand tremor in October 2011, which resolved by the end of the month. 10/07/2020, MTR–GF; 07/19/2012, STR–Medical–Photocopy. In November 2011, the Veteran reported experiencing occasional tremors, dyspnea during exertion and when lying down, and paroxysmal nocturnal dyspnea (PND). She also experienced postpartum mitral regurgitation. Mild proptosis of the eyes was observed in November 2011. 10/07/2020, MTR–GF. December 2011 treatment records demonstrate the Veteran was not experiencing symptoms of chills, weight loss, chest pain or discomfort, dyspnea coughing, nausea, vomiting, abdominal pain, abdominal tenderness, blood in stool, diarrhea, constipation, change in urinary frequency, urinary urgency, dysuria, or edema. The physician observed normal eye conjunctiva, eye sclera, lungs, respiration, heart rate and rhythm, and heart sounds. 10/07/2020, MTR–GF. A January 2012 treatment note indicates the Veteran no longer had dyspnea or a hand tremor; however, she felt fatigued and sluggish. The Veteran had complaints of palpitations, lightheadedness, nausea, sore throat, and occasional headaches. The Veteran did not have blurry vision, pain with eye movement, diplopia, or abdominal pain. 07/19/2012, STR–Medical–Photocopy; 10/07/2020, MTR–GF. In December 2012, a Medical Corps physician noted the Veteran had no symptoms of fever, weight loss, chest pain, chest discomfort, dyspnea, cough, nausea, vomiting, abdominal pain, bright red blood per rectum, constipation, change in urinary frequency, urinary urgency, or dysuria. The Veteran complained of an upset stomach, and she had symptoms of chills and diarrhea once that day. In February 2013, an ultrasound of the Veteran’s stomach revealed an abdominal bruit appreciated. The Veteran stated she was constipated and had stools smaller than typical. The physician noted intermittent pain periumbilical, worse with a low level of pressure, but no appetite changes, fever, chills, weight fluctuations, nausea, or vomiting. 10/07/2020, MTR–GF. A January 2014 treatment record notes the Veteran had no symptoms of fever, chills, recent weight loss, headache, chest pain, chest discomfort, dyspnea, cough, nausea, vomiting, abdominal pain, bright red blood per rectum, diarrhea, constipation, changes in urinary frequency, urinary urgency, or dysuria. Later in January 2014, a physician noted the Veteran missed her medication for a week. Symptoms associated with hyperthyroidism included dyspnea, eye complaints, menstrual irregularity, and palpitations. Pertinent negatives comprised of abdominal pain, anorexia, cold intolerance, constipation, diarrhea, dry skin, dysphagia, fatigue, hair loss, heat intolerance, increased sweating, insomnia, leg swelling, lethargy, nausea, nervousness, pallor, paresthesias, weakness, weight gain, and weight loss. The physician also noted positive signs of tremors but observed no shortness of breath or palpitations during the visit. 10/07/2020, MTR–GF. During a March 2014 visit with a VA primary care provider, the Veteran reported enlargement of the thyroid gland (goiter), dyspnea, heart palpitations, tremors, and that she had not had her period for nine months. The Veteran denied fever, chills, sweating, weight loss, weight gain, appetite loss, difficulty sleeping, fatigue, restlessness, headaches, dizziness, sinus pain, sinus pressure, blurred vision, dry eyes, tearing, itchy eyes, ear pain, ear congestion, epistaxis, rhinorrhea, nasal discharge, nasal congestion sore throat, painful swallowing, swollen gums, dysphagia, neck pain, neck stiffness, swollen tender glands, chest pain, shortness of breath, cough, wheezing, chest congestion, orthopnea, pain radiating, heartburn, flatulence, constipation, diarrhea, nausea, vomiting, incontinence, hematemesis, hematochezia, melena, discharge, hematuria, dysuria, nocturia, frequency, hesitancy, pain, incontinence, dysmenorrhea, amenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, cramping, passing clots, hot flashes, irritability, joint swelling, muscle swelling, joint pain, muscle pain, limited range of motion, rigidity, limb clumsiness, paresthesias, numbness, paralysis, agitation, confusion, anxiety, depression, mania, hypomania, suspiciousness, hearing voices, hallucinations, grieving, or suicidal ideation. 10/07/2020, MTR–GF; 03/23/2019, CAPRI. The March 2014 physician observed a supple neck, no lymphadenopathy, palpable carotid pulses, no bruit, no neck tenderness, no JVD, no thyromegaly, that lungs were clear to auscultation bilaterally, no wheezing, no rhonchi, no rales, nonlabored respirations, normal chest excursion and normal to percussion, regular heart rate and rhythm and sound, the abdomen was soft and non-tender, a non-distended abdomen, the strength of the reflexes were normal, the strength of extremities were normal, extremities were warm to touch, and no tremors as demonstrated by the Veteran’s ability to follow commands. Id. In an April 2014 medical appointment, the Veteran denied current chest pain but reported weak pain that occurs at rest and last one to two hours. The Veteran also denied shortness of breath or radiating pain. The Veteran reported good general overall feeling and health. 10/07/2020, MTR–GF. In May 2014, the Veteran denied current palpitations, sweating, diarrhea, or tremors. Her weight was noted as stable, around 130 pounds. She stated that she has been more symptomatic in the past, including a heart failure after the birth of her youngest child. 03/23/2019, CAPRI. A June 2014 treatment record notes the Veteran complained that over the past several months, she has had episodes of substernal chest pain described as a sharp sensation lasting for several minutes to an hour. The pain is usually associated with shortness of breath but not her palpitation episodes. Her weight was 129 pounds, and her pulse was 117 BPM. The examiner noted intermittent lower extremity edema, which was likely secondary to venous insufficiency. 10/07/2020, MTR–GF. A February 2015 physician analyzed diagnostic testing and found Graves’ disease is doing well on medical management. The Veteran continues to have elevated heart rate and palpitations but no specific chest pain, shortness of breath, dizziness, or syncope. A June 2014 Graves’ disease two-dimensional echocardiogram revealed grade II diastolic dysfunction, mild mitral valve regurgitation and normal left ventricular ejection fraction (LVEF). A June 2014 Nuclear stress test revealed normal LV function and no ischemia or infarction. A June 2014 Holter monitor test revealed sinus rhythm/elevated myocardial infarction (SR/ST) throughout with rare premature atrial contractions/premature ventricular contractions (PACs/PVCs) and a high average heart rate of 102 and a maximum heart rate of 148. The physician noted that past mitral valve regurgitation and hypertension improved subsequently once thyroid disorder and blood pressure improved in 2011. 10/07/2020, MTR–GF. In March 2015, the Veteran weighed 141 pounds, and her pulse was 101 BPM. The physician noted tachycardia and palpitations symptoms were typically present only when more the Veteran is more active. Her diastolic dysfunction, blood pressure, and hypertension were controlled. She had lower extremity edema. The Veteran denied any chest pain, chest pressure, shortness of breath either at rest or on exertion, PND, dizziness, palpitations, presyncope, or syncope. 10/07/2020, MTR–GF. In July 2015, the Veteran weighed 136.03 pounds, and no abnormalities were noted. A February 2016 treatment note indicates no weight change, fever, night sweats, vision problems, constipation, diarrhea, bowel movement changes, urinary discomfort, weakness, tingling, numbness, depression, or anxiety. 03/23/2019, CAPRI. An August 2016 treatment record notes the Veteran denied cough or dyspnea symptoms. The Veteran weighed 139 to 140 pounds, and her pulse rate was 106 BPM. The physician observed no JVD, no thyroid nodules or enlargement, the abdomen was soft and non-tender, no masses in the abdomen, bowel sounds were normal. The physician explained tachycardia and palpitation symptoms were typically only present when the Veteran was more active, the Veteran had lower extremity edema, and that the Veteran’s heart rate and hypertension were well controlled. 10/07/2020, MTR – Non-GF. In an August 2016 VA examination, the Veteran reported fatigue, episodic tachycardia, diarrhea, and irregular periods. The examiner noted gastrointestinal issues, intermittent tachycardia, increased blood pressure, continuous medication, fatigability, thyroid enlargement, and irregular or absent menstrual periods. The results of laboratory testing conducted in February 2016 demonstrated thyroid-stimulating hormone (TSH) of less than 0.004 uIU/mL (below the normal range of 0.5-5.000), Free T4 for thyroid gland function of 1.07 ng/dL (within the normal range of 0.70-1.48), and calcium test results were 9.8 mg/dL (within the normal range of 8.4-10.4). The examiner found the Veteran’s thyroid or parathyroid condition would require the Veteran to need a flexible work schedule to accommodate her symptoms of Graves’ disease. 08/12/2016, C&P Exam. In September 2016, the Veteran reported increased pain on one side of her throat, sinus congestion, a cough, diarrhea, and diplopia. She denied fever, vomiting, chest pain with a deep breath, shortness of breath, wheezing, palpitations, dyspnea, chest pain, vision loss or changes, tremor, anxiety, or insomnia. Her pulse was 106 BPM, and her weight was 137.3 pounds. 03/23/2019, CAPRI. In December 2016, the Veteran denied any recent chest discomfort, palpitations, and diarrhea. The physician noted her chest pressure was a 5/10 in intensity without associated dyspnea, diaphoresis, or radiation, and it resolved spontaneously after one hour. The Veteran develops dyspnea on exertion after climbing up one flight of stairs and has occasional orthopnea without PND. The Veteran weighed 139 pounds, and her pulse was 105 BPM. The Veteran’s eyes, neck, chest, heart, lungs, abdomen, extremities, mood, and affect all appeared normal upon examination. The electrocardiogram during the checkup demonstrated normal sinus rhythm 93 BPM with possible left atrial enlargement and poor R wave progression; the physician noted no prior electrocardiogram was available for comparison. 10/07/2020, MTR–Non-GF. A March 2017 physician observed the Veteran was a very poor historian, which required the physician to obtain the Veteran’s medical history by reviewing medical records accompanying the Veteran. The Veteran denied any gastrointestinal symptoms, joint pains, rashes, or fever on methimazole. She denied any unexplained weight loss, palpitations, tremors, unexpected anxiety, heat or cold intolerance, compressive neck symptoms, or eye symptoms. The Veteran currently owns her own business. The physician observed normal pupils, mild periorbital edema (puffy eyes), intact extraocular movements, no exophthalmos, slightly enlarged thyroid gland approximately one and half times normal, and no lymphadenopathy on the neck. The physician also observed normal head, neck, lungs bilaterally, cardiovascular, abdomen, extremities, mood, and affect. The absence of tremors or lower extremity edema was specifically noted. The Veteran’s weight was 144 pounds, and her pulse was104 BPM and regular. 10/07/2020, MTR–Non-GF. An October 2017 VA treatment note recorded the Veteran’s weight at 140.4 pounds, pulse at 100 BPM, a low potassium level. 03/23/2019, CAPRI. In June 2018, the Veteran reported feeling anxious, a faster heartbeat than normal, and swelling in her ankles. She denied chest pain, shortness of breath, orthopnea, PND, or palpitations. Id. In October 2018, the Veteran denied fever, night sweats, chills, fatigue, unintentional weight loss, change in appetite or activity, head injury, vision changes, eye pain, light sensitivity, discharge, chest pain or pressure, palpitations, lower extremity edema, shortness of breath, cough, wheeze, chest tightness, bloody sputum, voiding urgency, dysuria, hematuria, arthralgia, myalgia, back pain, neck pain, gout, change in gait, memory loss, numbness or tingling, tremor, or weakness. The Veteran reported having depression but denied having anxiety, hallucinations, trouble sleeping, or suicidal thoughts. The Veteran’s pulse was 78 BPM, and she weighed 139 pounds. The examiner observed normal eyes, a normal neck with thyroid slightly palpable, and normal cardiovascular, respiratory, and musculoskeletal systems. Id. In January 2020, the Veteran’s weight was 130 pounds. The physical examination was negative for evidence of chest pain, irregular rhythm, edema, nausea, vomiting, diarrhea, bowel sounds, dysuria, hematuria, voiding frequency, voiding urgency, or voiding burning sensation. 09/21/2020, CAPRI A May 2020 treatment record notes no evidence of fevers, chills, weakness, dizziness, nights sweats, sudden weight change, visual changes, watery eyes, eye irritation, eye pain, blurred vision, double vision, night vision problems, swollen gland or lumps, chest pain, palpitations, orthopnea or dyspnea on exertion, cough, wheezing or dyspnea, hemoptysis, poor appetite, heartburn, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, seizures, tremors, headaches, depression, anxiety, or insomnia. The Veteran stated she was feeling better with her methimazole 10 mg 2 tablets twice a day dose maintenance. July 2020 VA treatment records document no symptoms, and state hyperthyroidism is controlled. The Veteran’s pulse was 78 BPM, and her weight 128 pounds. In September 2020, the Veteran complained of constipation, dry and itchy skin, feeling sluggish, and brittle hair. Id. The Veteran’s concerns with the adequacy of the VA examinations conducted in 2011 and 2012, because the examiners were not endocrinologists or cardiologists, are recognized; however, the examiners are Board-certified medical doctors and are found competent to conduct the examination, the examination is consistent with contemporaneous treatment records; thus, the examinations are adequate and provide an accurate picture of the Veteran’s disability picture from her service-connected Graves’ disease. See 10/20/2012, Correspondence; 08/16/2011, Correspondence. The record demonstrates a disability rating of 100 percent is not warranted for the entire period on appeal, under any applicable version of DC 7900. For the entire period on appeal the Veteran displayed symptoms of tachycardia, increased pulse pressure or blood pressure, and the need for continuous medication required for control of her Graves’ disease. The Veteran’s medical record is negative for significant evidence of eye involvement for the entire period on appeal. The mild proptosis of the eyes was observed in July 2010 and November 2011 following the Veteran’s postpartum mitral regurgitation; however, the evidence demonstrates the proptosis was not an ongoing symptom, and the record is negative for eye disorder symptoms attributable to Graves’ disease. The Veteran’s contention of diplopia is recognized; however, the Veteran is not competent to diagnose diplopia, and no examiner has diagnosed or observed diplopia. The medical evidence is negative for significant evidence of muscular weakness for the entire period on appeal; all examinations demonstrate normal strength and no weakness, apart from a complaint of muscle weakness in November 2010. The medical evidence does not demonstrate a symptom of weight loss. The Veteran’s weight ranged from 129 to 141 pounds during the 11-year appeal period with no large fluctuation at any time, except for when she was pregnant in 2011. The medical evidence is negative for significant evidence of a sympathetic nervous system for the entire period on appeal. The Veteran consistently denied symptoms attributed to a sympathetic nervous system such as excessive sweating, heat and cold intolerance, or hot flashes and chills throughout the appeal period. a. Prior to December 1, 2011. The record demonstrates an initial rating of 60 percent, but no higher, for Graves’ disease is warranted prior to December 1, 2011. The Veteran’s Graves’ disease was not well-controlled prior to December 1, 2011. A December 2010 treatment note indicates her thyroid gland was about 2.5 times the normal size. During this period, the Veteran suffered from gastrointestinal problems such as chronic diarrhea and symptoms of voiding urgency, which is not contemplated by the Veteran’s service-connected GERD. The Veteran also had occasional symptoms of fatigue and insomnia. The evidence demonstrates issues with the Veteran’s Graves’ disease treatment during her pregnancy from January 2011 to October 2011, culminating in a postpartum mitral regurgitation. The medical evidence is negative for significant evidence of emotional instability attributable to Graves’ disease before December 1, 2011. With exception to the February 2011 VA examination, the Veteran has consistently denied feelings of depression, anxiety, and emotional instability. All examination and treatment notes describe the Veteran’s mood and affect as normal. As the Veteran did not have symptoms of eye involvement, muscular weakness, loss of weight, and sympathetic nervous system, or cardiovascular symptoms (until October 2011), a higher rating of 100 percent is not warranted before December 1, 2011. The Veteran’s postpartum mitral regurgitation in October 2011 is recognized; however, those symptoms are contemplated under the Veteran’s other service-connected disability of severe mitral and tricuspid valve regurgitation with congestive heart failure associated with Graves’ disease rated under DC 7099-7005 effective October 20, 2011, with a 60 percent disability rating. To rate this disability under DC 7900 rather than under DC 7099-7005 would result in a lower overall rating for the Veteran. Under the new regulations, the Veteran’s symptoms of tachycardia, hypertension, and gastrointestinal problems could be rated under separate diagnostic codes rather than a single rating under DC 7900. However, a finding under the new regulation would result in a lower rating for the Veteran as all the Veteran’s cardiovascular symptoms (tachycardia, hypertension, and status-post severe mitral and tricuspid valve regurgitation with congestive heart failure) would be rated under DC 7008. The Veteran’s gastrointestinal symptoms would warrant a 30 percent rating during this period under 38 C.F.R. § 4.114, DC 7319. All possibly applicable diagnostic codes were considered, but the Veteran could not receive a higher disability rating than 60 percent for Graves’ disease prior to December 1, 2011. See Schafrath, 1 Vet. App. at 593; 38 C.F.R. § 4.119, DC 7900. b. From December 1, 2011, to August 11, 2016. The relevant medical and lay evidence demonstrate a rating in excess of 30 percent is not warranted for Graves’ disease. The medical evidence is negative for evidence of a thyroid gland enlargement from December 1, 2011, to August 11, 2016. All examinations and treatment notes from this period demonstrate a normal-sized thyroid gland and absence of goiter. The Veteran self-reported goiter during this period, but the record contains no medical evidence to corroborate her self-report. The record from December 1, 2011, to August 11, 2016, is negative for any evidence of emotional instability related to Graves’ disease. The Veteran consistently denied feelings of depression, anxiety, and emotional instability during this period, and all examination and treatment notes describe the Veteran’s mood and affect as normal. The medical evidence from December 1, 2011, to August 11, 2016, demonstrate the Veteran’s severe gastrointestinal symptoms had resolved during this time, with the Veteran consistently denying the presence of gastrointestinal symptoms except for one instance of diarrhea in December 2012 and an occurrence of constipation in February 2013. Under the new regulations, the Veteran’s combined cardiovascular symptoms would not render a higher evaluation than that of the evaluation under DC 7099-7005 and DC 7900 before December 10, 2017, and the Veteran’s gastrointestinal symptoms during this time would be non-compensable under DC 7319. All possibly applicable diagnostic codes were considered, but the Veteran could not receive a higher disability rating than 30 percent for Graves’ disease from December 1, 2011, to August 11, 2016. See Schafrath, 1 Vet. App. at 593; 38 C.F.R. § 4.119, DC 7900. c. As of August 12, 2016. The relevant medical and lay evidence demonstrate a rating in excess of 60 percent is not warranted for Graves’ disease as of August 12, 2016. Goiter was observed during the August 2016 VA examination and again by a March 2017 physician. The August 2016 VA examiner noted diarrhea symptoms. The Veteran reported diarrhea in September 2016; however, all examinations and check-ups since are negative for abdominal and gastrointestinal issues. The record during this time contains evidence of emotional instability, which is possibly attributable to Graves’ disease. In June 2018, the Veteran reported feeling anxious. In October 2018, the Veteran denied feeling anxiety but reported depression. In May 2020, the Veteran reported feeling sluggish. Under the new regulations, the Veteran’s combined cardiovascular symptoms would not render a higher evaluation than the evaluation provided under the old regulations rated under DC 7099-7005 and DC 7900, and the Veteran’s gastrointestinal symptoms as of August 12, 2016, would be non-compensable under DC 7319. There is no basis for a rating in excess of 60 percent for Graves’ disease under any of the applicable criteria as the Veteran’s occasional goiter and gastrointestinal symptoms are contemplated by the 60 percent rating, and the Veteran has no symptoms of eye involvement, muscular weakness, weight loss, or a sympathetic nervous system. The Veteran was last afforded a VA examination in August 2016; however, the 2016 VA examination and testing is adequate and provides an accurate picture of the Veteran’s disability picture from her service-connected Graves’ disease and enables the Board to rate the disability. Medical treatment records dating through 2020 have been reviewed, but these do not show any complaints or treatment relating to Graves’ disease other than to monitor the condition. Neither the Veteran nor the representative argued that the Veteran’s Graves’ disease has increased in severity since the last examination. Therefore, a new examination is not warranted at this time. All possibly applicable diagnostic codes were considered, but the Veteran could not receive a higher disability rating than 60 percent for Graves’ disease as of August 12, 2016. See Schafrath, 1 Vet. App. at 593; 38 C.F.R. § 4.119, DC 7900. TDIU 2. Entitlement to a TDIU. VA may grant a total disability rating where the schedular rating is less than 100 percent, and the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16. Here, however, the Veteran is in receipt of a 100 percent schedular rating for the entire appeal period since her separation from active duty in December 2009. Nonetheless, an award of a 100 percent disability rating does not always render the issue of TDIU moot. VA’s duty to maximize a claimant’s benefits includes considering whether her disabilities establish entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Specifically, SMC may be warranted if the Veteran has a 100 percent disability rating for a single disability, and VA finds that TDIU is warranted based solely on the disabilities other than the disability rated at 100 percent. See Bradley, 22 Vet. App. at 294 (analyzing 38 U.S.C. § 1114(s)). In this case, however, the Veteran does not have a single disability rated 100 percent disabling, but rather a 100 percent combined rating based on multiple disabilities. Thus, there is no basis for the assignment of SMC per § 1114. Therefore, the award of a TDIU would result in no further benefit, and the issue of entitlement to a TDIU is rendered moot. The issue of entitlement to a TDIU need not be considered. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley, 22 Vet. App. at 294. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Costa, 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.