Citation Nr: 21026855 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-20 643 DATE: May 4, 2021 REMANDED Entitlement to an initial compensable rating for residuals of antiphospholipid antibody syndrome is remanded. Entitlement to a rating of total disability based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from June 1999 to May 2005. This case comes on appeal of a March 2012 rating decision. The Veteran testified before the Board at a virtual hearing in February 2021. A transcript of that hearing is of record. 1. Entitlement to an initial compensable rating for residuals of antiphospholipid antibody syndrome is remanded. 2. Entitlement to a rating of total disability based on individual unemployability (TDIU) is remanded. As a preliminary matter, the Board notes that the Veteran raised the issue of entitlement to a TDIU during the pendency of the claim. Although the agency of original jurisdiction (AOJ) adjudicated the issue of TDIU in an April 2017 rating decision, the Board nevertheless takes jurisdiction of it here, as it is considered part and parcel of the Veteran's increased rating claim. However, TDIU is inextricably intertwined with the evaluation of residuals of antiphospholipid antibody syndrome and must therefore be remanded as well. By way of background, the Veteran filed a claim of entitlement to service connection for antiphospholipid antibody syndrome in June 2005, within one year of separation from service. Her claim was initially denied, with the AOJ finding that the condition was a lab finding and not a disability for which benefits could be granted. Eventually, in the March 2012 rating decision on appeal, the AOJ granted an evaluation for antiphospholipid antibody syndrome, effective May 2005, but rated it at 0 percent. Thus, the initial rating remains on appeal. The record shows that antiphospholipid antibody syndrome is currently rated by VA under Diagnostic Code 6350. As the Veteran has noted in her statements to VA, this is the Diagnostic Code for lupus. There is no rating code specifically for antiphospholipid antibody syndrome; therefore, the AOJ attempted to rate the disability based on an analogous condition in the rating schedule. 38 C.F.R. § 4.20 ("When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.") Although antiphospholipid antibody syndrome and lupus are both autoimmune disorders, the rating schedule for lupus may not encompass the entirety of the effects that antiphospholipid antibody syndrome presents. According to the National Institute of Health's National Heart, Lung, and Blood Institute, antiphospholipid antibody syndrome can result in blood clots, which, in turn can lead to numerous other symptoms. In diagnosing the condition, the Veteran's physician, Dr. M.P., noted, "Although management of the anticoagulation itself is simple enough, the potential for complications in this syndrome is high, and she should be followed by an internist/nephrologist with rheumatic consultation...It may well be that the picture will have evolved and confirmatory or other diagnoses will become apparent." To some extent, it appears that the Veteran has been rated for manifestations or complications of antiphospholipid antibody syndrome already. Indeed, the Veteran's service-connected disability list includes a kidney condition that was linked to antiphospholipid antibody syndrome. The Veteran has also noted that the condition effectively makes it impossible to treat endometriosis. As such, she has been service-connected for endometriosis, as well as for a hysterectomy, related to endometriosis. However, the Veteran contends that there are additional manifestations of antiphospholipid antibody syndrome that have not been service-connected. These symptoms include joint pain, memory issues, fatigue, anemia, migraines, shortness of breath, speech changes, and nausea. The Board notes that VA has a duty to maximize benefits that, in turn, requires it to exhaust all schedular alternatives that are reasonably raised by the record. This includes not just analogous ratings, but consideration of secondary service connection for manifestations of the underlying disability that are not contemplated by the analogous rating criteria. See Morgan v. Wilkie, 31 Vet. App. 162 (2019). Here, the Veteran has testified that a number of her current symptoms are manifestations of antiphospholipid antibody syndrome, as well as treatment thereof, that have not been considered in the rating of the disability. Unfortunately, the Board does not have the medical expertise necessary to confirm or deny whether these symptoms are etiologically related, and the medical evidence of record fully establish each relationship. Accordingly, a new VA examination is necessary to evaluate the full scope of the current condition and to address any secondary manifestations that may require separate rating. The Board notes that the Veteran is also encouraged to submit any findings from her own personal physicians describing any recurrent manifestations of antiphospholipid antibody syndrome, or medication taken to treat the disability. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate examiner who is qualified to evaluate autoimmune diseases. The examiner should then evaluate the current severity of the antiphospholipid antibody syndrome. In doing so, the examiner should provide a full description of the disability as well as a description of any associated manifestations. The examiner should specifically note that antiphospholipid antibody syndrome is not a disability that is contemplated by VA's rating schedule. As such, VA must rate by analogy the syndrome itself, as well as any manifestations that are proximately caused or aggravated by it. Accordingly, the examiner should address whether it is at least as likely as not (i.e., 50 percent probability or greater), that any additional symptoms described by the Veteran are caused or aggravated beyond their natural progression by antiphospholipid antibody syndrome. This list should include, but is not limited to: joint pain, memory issues, fatigue, anemia, migraines, shortness of breath, speech changes, and nausea. If the examiner determines that he or she cannot make such a determination, he or she should provide a full explanation as to why that is the case. The examiner should also address whether it is at least as likely as not that medication taken for the treatment of antiphospholipid antibody syndrome causes or aggravates beyond their natural progression any additional disabilities. (Continued on Next Page) 2. Once the above development has been achieved, as well as any other development deemed necessary thereafter, readjudicate the appeal. If any benefits sought remain denied, issue a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.