Citation Nr: 21009216 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 16-27 864 DATE: February 19, 2021 ORDER Entitlement to a compensable rating for embolism and thrombosis of the iliac artery is denied. FINDING OF FACT The Veteran's embolism and thrombosis of the iliac artery has not manifested with claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less. CONCLUSION OF LAW The criteria for entitlement to a compensable rating for embolism and thrombosis of the iliac artery have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.104, Diagnostic Codes 7199-7111. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1965 to October 1967. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In July 2019, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. In August 2020, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). 1. Entitlement to a compensable rating for embolism and thrombosis of the iliac artery. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 ;38C.F.R. §4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period for which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000) (Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s embolism and thrombosis of the iliac artery associated with coronary artery disease is rated under Diagnostic Code 7199- 7111. Hyphenated Diagnostic Codes are used when a rating under one diagnostic code requires use of an additional Diagnostic Code to identify the basis for the assigned rating; the additional code is shown after the hyphen. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. 38 C.F.R. § 4.27. The hyphenated diagnostic code indicates that the Veteran’s disability is rated under the criteria for a large artery aneurysm, Diagnostic Code 7111. Under Diagnostic Codes 7111, claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less is rated 20 percent. Claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less is rated 40 percent. Claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; persistent coldness of the extremity, one or more deep ischemic ulcers, or ankle/brachial index of 0.5 or less is rated 60 percent. Ischemic limb pain at rest, and; either deep ischemic ulcers or ankle/brachial index of 0.4 or less (following surgery); and if symptomatic, or; for indefinite period from date of hospital admission for surgical correction is rated 100 percent. 38 C.F.R. § 4.104. The criteria under Diagnostic Code 7111 are conjunctive, not disjunctive. Thus, all criteria must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met). The ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure. The normal index is 1.0 or greater. 38 C.F.R. § 4.104, Diagnostic Codes 7111, Note (1). Claudication is defined as "limping or lameness," and intermittent claudication is "a complex of symptoms characterized by pain, tension, and weakness in a limb when walking is begun." Dorland's Illustrated Medical Dictionary 369 (32nd ed. 2012). The Veteran is currently assigned a 0 percent rating for embolism and thrombosis of the iliac artery associated with coronary artery disease, effective May 8, 2015. The Veteran contends that the rating assigned for service-connected embolism and thrombosis of the iliac artery associated with coronary artery disease do not accurately compensate the severity of the disability, and that higher ratings are warranted. In January 2015, the Veteran underwent surgery to address a left iliac obstruction. During that surgery, the left common iliac artery was stented. As a result, the artery was wide open, and no complications were noted. During VA examination in June 2015, the examiner diagnosed embolism and thrombosis of the iliac artery (January 2015), occlusion of the carotid artery without cerebral infarction (March 2009), and peripheral vascular disease (March 2009). The examiner noted the Veteran as undergoing an iliac bypass in 2014 and a carotid endarterectomy in 1995. The examiner further noted that the Veteran has a medical history which includes obstruction of the coronary, carotid, and iliac arteries. In January 2015, the Veteran underwent a surgical procedure of an obstructed left iliac artery. The surgery restored flow to the leg and claudication resolved. The examiner remarked that since the surgery, the Veteran’s leg function was restored. During VA examination in August 2016, the examiner acknowledged the Veteran to be diagnosed with peripheral vascular disease, first diagnosed in 1995. The examiner noted the Veteran as having a pulse of 62 beats per minute and three blood pressure readings of 180/72, 120/78, and 116/72. All the peripheral pulses for the upper and lower extremities were 2+. The Veteran did not have a change in diagnosis from embolism and thrombosis of the iliac artery. The Veteran’s condition was active at the time of this examination. The examiner noted that the Veteran was unable to climb 100-foot poles, walk, or stand for a length of time without moderate pain. The examiner stated the Veteran did not have post-phlebitic syndrome of any etiology nor any signs or symptoms of peripheral vascular disease. During a July 2019 Board hearing, the Veteran alleged a worsening of the disability. The Veteran stated that he had difficulty walking for days on end and complained of left leg weakness, difficulty walking more than 50 yards, and swelling. Subsequently, during VA examination in September 2020, the examiner diagnosed embolism and thrombosis of the iliac artery and peripheral vascular disease. The examiner stated that the service-connected disability was resolved and that the current complaints stemmed from peripheral vascular disease. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The record currently contains no other examinations that are valid for rating purpose. Accordingly, the Board finds that the Veteran has not provided medical evidence that would lead to entitlement to an increased rating under Diagnostic Code 7199-7111. A compensable rating is not warranted as there is no medical evidence that indicates the Veteran as experiencing claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less as is contemplated by a 20 percent pursuant to Diagnostic Code 7111. (Continued on the next page)   While the Veteran did report difficulty walking more than 50 yards during his July 2019 Board Hearing and there is medical evidence to confirm that assertion, the Board notes that there is no evidence of the Veteran experiencing diminished peripheral pulses or ankle/brachial index of 0.9 or less since May 8, 2015, the effective date of this claim. In this regard, the Board again notes that the symptoms under Diagnostic Code 7111 are conjunctive, meaning they must all be present to warrant a higher rating. Melson v. Derwinski, 1 Vet. App. 334 (1991). The Veteran does not have all the symptoms to satisfy a rating of 20 percent. Thus, the current symptoms are more nearly approximated by the criteria for the current 0 percent disability rating. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an increased rating for embolism and thrombosis of the iliac artery associated with coronary artery disease. Therefore, the Board finds that the preponderance of the evidence is against the assignment of any higher ratings. Thus, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mondesir, Eric 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.