Citation Nr: 21013477 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 12-28 828 DATE: March 9, 2021 ORDER A 30 percent rating for residuals of cold injury of the left hand (previously rated as residuals of frostbite of the hands, Raynaud’s syndrome) is granted for the entire period on appeal prior to June 9, 2015, subject to the law and regulations governing the award of monetary benefits. A 30 percent rating for residuals of cold injury of the right hand (previously rated as residuals of frostbite of the hands, Raynaud's syndrome) is granted for the entire period on appeal prior to June 9, 2015, subject to the law and regulations governing the award of monetary benefits. A rating in excess of 30 percent for residuals of cold injury of the left hand is denied. A rating in excess of 30 percent for residuals of cold injury of the right hand is denied. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s cold injury residuals of the left hand have been manifested by cold sensitivity, color changes, and locally impaired sensation. 2. For the entire period on appeal, the Veteran’s cold injury residuals of the right hand have been manifested by cold sensitivity, color changes, and locally impaired sensation. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for a 30 percent rating for residuals of cold injury of the left hand have been met for the entire period on appeal prior to June 9, 2015; a rating in excess of 30 percent is not warranted for any portion of the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7122. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for a 30 percent rating for residuals of cold injury of the right hand have been met for the entire period on appeal prior to June 9, 2015; a rating in excess of 30 percent is not warranted for any portion of the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7122. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from October 1985 to March 1987. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In January 2015, the Board remanded this matter for additional development. In June 2015, after taking further action, the RO granted 30 percent ratings for residuals of cold injury of each hand under Diagnostic Code (DC) 7122, effective June 9, 2015. (Previously, the disability was rated under DC 7117 as “residuals of frostbite of hands, Raynaud’s syndrome,” evaluated as 20 percent disabling from February 1992.) In May 2017, the Board remanded the case to have the Veteran scheduled for a requested Board hearing. In January 2019, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. In September 2019, the Board again remanded the case to the agency of original jurisdiction (AOJ). The Board directed the AOJ to ask the Veteran to identify and provide appropriate releases for records of any private treatment he had received, to obtain updated VA treatment records, and to afford the Veteran a VA examination in connection with his claim. In November 2019, the AOJ asked the Veteran to identify and provide appropriate releases for any private treatment he had received. In December 2019, the Veteran provided a release, but he identified only VA treatment providers. The AOJ obtained updated VA treatment records in November 2019. In March and August 2020, it afforded the Veteran new VA examinations. The Board finds that the AOJ substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they have been raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is 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 C.F.R. § 4.3. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See also Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Entitlement to higher ratings for residuals of cold injury of the hands (previously rated as residuals of frostbite of the hands, Raynaud’s syndrome) The Veteran seeks a higher rating for the residuals of cold injury of his hands. He maintains, in essence, that he had symptoms warranting a 30 percent rating for each hand prior to June 9, 2015. As noted above, the cold injury of the Veteran’s hands was previously evaluated as residuals of frostbite of the hands, Raynaud’s syndrome, under DC 7199-7117, rated as 20 percent disabling from February 1992. Typically, 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 rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number is “built-up” as follows: the first two digits are selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the cardiovascular system, and the last two digits are to be “99” for all unlisted conditions. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27. As noted above, in a June 2015 rating decision, the AOJ changed the diagnostic code under which it rated the Veteran’s disability to DC 7122 for cold injury residuals, assigning a 30 percent rating for each hand, effective June 9, 2015. Inasmuch as both DC 7199-7117 and DC 7122 are applicable to the disability for which the Veteran seeks a higher rating, the Board has considered both DCs in rating the disability. Pursuant to DC 7117, a 10 percent rating is warranted when characteristic attacks occur one to three times per week; a 20 percent rating where there are characteristic attacks occurring four to six times per week; a 40 percent rating where there are characteristic attacks occurring at least daily; a 60 percent rating with two or more digital ulcers and a history of characteristic attacks; and a 100 percent rating with two or more digital ulcers plus autoamputation of one or more digits and a history of characteristic attacks. 38 C.F.R. § 4.104, DC 7117. For rating purposes, a characteristic attack consists of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or emotional upsets. Id., Note. The evaluations set forth in the DC are for the disease as a whole, regardless of whether the nose and ears are involved. Id. Pursuant to DC 7122, a 20 percent rating is warranted for arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). A maximum 30 percent rating is warranted for arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (as above). Note (1) to Diagnostic Code 7122 provides that amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, are to be rated separately under other diagnostic codes. Other disabilities that have been diagnosed as the residual effects of cold injury, such as Raynaud’s phenomenon, muscle atrophy, etc., are also to be rated separately, unless they are used to support a rating under Diagnostic Code 7122. Note (2) to Diagnostic Code 7122 provides that each affected part (e.g., hand, foot, ear, nose) is to be separately rated and combined in accordance with 38 C.F.R. §§ 4.25 and 4.26. A January 2009 VA treatment record shows that the Veteran went to the emergency room because his hands were cold and blue. He reported that he had been working outside all day with gloves, and that his hands were ice cold and aching. A diagnosis of Raynaud’s syndrome was noted. The Veteran submitted two lay statements in July 2009 from individuals who stated that they had observed that the Veteran’s fingertips were purple and white after being out in the cold. The Veteran was afforded a VA examination in February 2010. The examiner noted the Veteran’s report that he suffered from feeling cold discoloration in his hands despite using two pairs of gloves while doing roof work in cold weather, as well as his report of pain and decreased feeling in his hands from the cold. The examiner indicated that the Veteran used medications to treat the problem, that there was a history of Raynaud’s Phenomenon which affected the digits of both hands, and that he had attacks 4-6 times per week that lasted between 30 and 60 minutes. He also noted color changes in both hands and dark pigmentation over the knuckles, and found that the Veteran had pain in the joints of his fingers which was intermittent, aching, and moderate in severity. He also indicated that the Veteran had cold sensitivity and tingling in both hands, both of which he rated as moderate in severity, and that there was a history of decreased or lost sensations in both hands. There was no history of amputations or tissue loss, hyperhidrosis, weakness, swelling, muscle cramps after use, a history of fungal infections, breakdown or ulceration, nail abnormalities, stiffness of joints, change in skin thickness, or sleep disturbance due to the symptoms. The Veteran also had a normal gait, posture, and carriage, his reflexes, sensation, grip strength, and peripheral pulses were normal, there had been no auto-amputations, and there were no ulcerations. Still further, there was no pain on manipulation of the joints in the affected areas, edema, or muscle atrophy, and x-rays of the hands were within normal limits. The examiner opined that the condition had significant effects on the Veteran’s ability to work, including weakness, fatigue, and pain. Finally, the examiner noted that the effect on chores, shopping, sports, recreation, and traveling was mild, and that there was no effect on exercise, feeding, bathing, dressing, toileting, or grooming. In May 2010, the Veteran submitted four additional lay statements from individuals who stated that the Veteran used creams and two pairs of gloves to treat his hands, and/or that they had observed that his hands were discolored. A July 2013 VA treatment record shows that the Veteran reported increased pain. On examination, there was possible clubbing deformity in the DIP joints, but the Veteran’s nails showed no onychomycoses. He was diagnosed at that time with Raynaud’s syndrome and peripheral arterial disease. Hand x-rays were again taken but were normal. The Veteran underwent upper extremity arterial testing in April 2014. Providers noted that his overall circulation was normal based on the waveforms at rest, but noticed some changes in digital artery flow following compression which they found could be related to spasm or to his underlying Raynaud’s. A July 2014 VA treatment record noted that there was no swelling or tenderness on examination, but an Allen’s test showed decreased ulnar artery flow in the right upper extremity and ulnar artery occlusion in the left upper extremity. The Veteran also had palpable pulses in both upper extremities. The provider noted that brachial indices of the upper extremities demonstrated vascular disease, but that without vasodilation during the tests, it was difficult to concretely attribute the Veteran’s poor indices to chronic vasoocclusion versus vasospasm from Raynaud’s. In an April 2015 VA treatment record the Veteran reported that he was having daily episodes, but denied any ulcers, skin changes, shortness of breath, or dysphagia, among other things. On examination, his hands were positive for clubbing, but there were no digital ulcers, skin changes, significant synovitis, or pitting of the nails. The Veteran was afforded a VA examination in June 2015, at which time the examiner filled out both Peripheral Nerves and Cold Injury Residuals Disability Benefits Questionnaires (DBQs). In the Peripheral Nerves DBQ, the examiner noted the diagnosis of Raynaud’s syndrome in the upper extremities and indicated that the Veteran did not have constant pain, but that he did have intermittent pain and numbness, both of which he rated as mild. He also noted that he had paresthesias and/or dysesthesias in the upper extremities which he rated as moderate. The Veteran had full strength and no atrophy, his reflexes were normal, he had no trophic changes, and his gait was normal. He had normal sensation in the shoulders and inner/outer forearms, but decreased sensation in the hands/fingers. The examiner indicated that the Veteran had mild incomplete paralysis of the radial nerves bilaterally, and that all other nerve testing was normal. The Veteran did not use an assistive device, and the examiner opined that Raynaud’s syndrome did not impact his ability to work. In the Cold Injury Residuals DBQ, the examiner noted the diagnosis of residuals of frostbite of the hands. The examiner indicated that the Veteran had arthralgias or other pain, cold sensitivity, color changes, hyperhidrosis, numbness, locally impaired sensation, and nail abnormalities in both hands. X-rays were not taken, and the examiner opined that the condition did not impact the Veteran’s ability to work. A September 2018 VA treatment record shows that examination at that time revealed no synovitis, no Raynaud’s or digital ulcers, and no sclerodactyly, but the examination was positive for clubbing. A January 2019 VA treatment record showed no cyanosis, digital ulcers, erythema, or synovitis, but again showed clubbing in all of the digits of the upper extremities. An April 2019 VA treatment record indicated that the Veteran was without clinical signs of Raynaud’s disease inasmuch as serologic testing had been negative to date. On examination, the Veteran’s hands were notable for clubbing in all of the digits, but there were no lesions or signs of gangrenous changes. The Veteran was afforded a third VA examination in March 2020, when the examiner completed Cold Injury Residuals and Hand and Finger DBQs. In the Cold Injury Residuals DBQ, the examiner noted the diagnosis of cold injury residuals to both hands and indicated that symptoms included only cold sensitivity and numbness in both hands. She also noted that x-rays of the hands were normal in July 2013 and recorded the results of the April 2014 upper extremity arterial study. She noted that the Veteran occasionally used 2 pairs of gloves when exposed to the cold and opined that the condition impacted the Veteran’s ability to work inasmuch as he would be unable to work in the cold. In the Hands and Fingers DBQ, the examiner again noted the diagnosis and indicated that the Veteran did not report flare-ups or functional loss. On examination, all range of motion testing was normal on both active and passive testing, there was no objective evidence of pain on non-weight bearing, and there was no evidence of pain with the use of the hands or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of either hand. The Veteran was able to perform repetitive use testing with no additional loss of range of motion. The examiner also indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or with flare-ups, and that there were no additional contributing factors of disability. The Veteran’s strength was full, and he had no atrophy or ankylosis. The examiner repeated that the impact on work function was that the Veteran was unable to work in the cold. The Veteran was afforded a fourth VA examination in August 2020, when the examiner provided Artery and Vein Conditions and Peripheral Nerves Conditions DBQs. On the Artery and Vein Conditions DBQ, the examiner found that the Veteran had both Raynaud’s disease and peripheral vascular disease but indicated that the symptomatology of the latter was limited to the lower extremities. Regarding Raynaud’s disease, he indicated that the Veteran had characteristic attacks less than once a week, that he had no digital ulcers, and that he did not have any autoamputation or other amputation of an extremity due to a vascular condition. The examiner opined that the Veteran’s vascular condition(s) did not impact his ability to work. In the Peripheral Nerves DBQ, the examiner found that the Veteran did not have a peripheral nerves condition or peripheral neuropathy, and that he also had no symptoms attributable to any peripheral nerve condition. The Veteran’s strength was full and he had no atrophy, his reflexes and sensation were normal, there were no trophic changes, Phalen’s and Tinel’s signs were negative, and all nerve testing, including that of the radial nerve, was normal. After careful review of the evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that 30 percent ratings for cold injury residuals of each hand pursuant to DC 7122 are warranted for the entire period on appeal prior to June 9, 2015. The February 2010 VA examination demonstrates that the Veteran had cold sensitivity, color changes, and locally impaired sensation at that time, which is consistent with a 30 percent rating for each hand. The Board notes that while a 30 percent rating for each affected part is the maximum rating available under DC 7122, Note (2) to Diagnostic Code 7122 provides that each affected part (e.g., hand, foot, ear, nose) is to be separately rated and combined in accordance with 38 C.F.R. §§ 4.25 and 4.26. This means that the Veteran’s combined rating for cold injury residuals of the hands is 60 percent when taking into account the bilateral factor. The Board has considered whether the evidence would support a higher rating under DC 7117 for Raynaud’s syndrome for any portion of the period on appeal. As noted above, the next highest rating available under DC 7117 is 100 percent, which requires two or more digital ulcers plus autoamputation of one or more digits and a history of characteristic attacks. The Veteran has never had any digital ulcers or autoamputation. A 100 percent rating under DC 7117 is therefore not warranted. The Board also notes that inasmuch as a 60 percent rating under DC 7117 also requires two or more digital ulcers, DC 7122 is the more favorable DC under which to rate the Veteran’s cold injury residuals of his hands for the entire period on appeal. The Board has also considered whether separate ratings are warranted for other disabilities that have been diagnosed as the residual effects of cold injury pursuant to Note (1) of DC 7122, including Raynaud’s phenomenon, peripheral vascular disease, and radial nerve paralysis. While the evidence of record indicates that the Veteran has been diagnosed with Raynaud’s syndrome, DC 7122 instructs VA adjudicators to separately rate that disability unless it is used to support an evaluation under DC 7122. DC 7117 for Raynaud’s indicates that a characteristic attack consists of color changes of the digits, and characteristic attacks are required for every rating under DC 7117. Inasmuch as the symptom of color changes of the digits has been used to support the awards of 30 percent ratings for each hand under DC 7122, a separate rating for Raynaud’s under DC 7117 is not warranted. Similarly, while the August 2020 Artery and Vein DBQ demonstrates a diagnosis of peripheral vascular disease, the examiner indicated that the disability manifested in the Veteran’s lower, not upper, extremities. Of note, the Veteran was denied service connection for frostbite of his feet and legs in a July 2008 rating decision. Therefore, the evidence does not support a separate rating for peripheral vascular disease of the hands, as there is no evidence which suggests that the disability causes symptoms in his upper extremities. Finally, the August 2015 VA examiner indicated that the Veteran had mild incomplete paralysis of the radial nerves bilaterally. That finding is directly contradicted, however, by the August 2020 examiner’s finding that all nerve testing, specifically including the radial nerves, was normal. Given the evidence of record as a whole, including the most recent VA examination findings, the June 2015 examination finding appears to be isolated and unsupported by the remainder of the record. The Veteran has also not contended that a separate rating for any nerve paralysis is warranted. The Board also finds that there is no other evidence of record that suggests that the Veteran has any other disabilities that have been diagnosed as the residual effects of cold injury. In light of the above, the Board finds that 30 percent ratings for cold injury residuals of each hand are warranted for the entire period on appeal prior to June 9, 2015 pursuant to DC 7122. The preponderance of the evidence is against assigning a higher, 100 percent rating pursuant to DC 7117, for any portion of the period on appeal, and against assigning separate disability ratings based on disabilities that have been diagnosed as the residual effects of cold injury. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Oldroyd, Associate 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.