Citation Nr: 21026957 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-33 118 DATE: May 4, 2021 ORDER Entitlement to a disability rating of 60 percent for hypothyroidism with hyperthyroidism (diagnosed as Grave's disease) is granted. FINDING OF FACT The Veteran's hypothyroidism with hyperthyroidism is productive of fatigue, constipation, mental disturbance, muscle weakness, cold intolerance, weight gain, and sleepiness, some of which are addressed by ratings assigned to her other disabilities. CONCLUSION OF LAW The criteria for entitlement to a 60 percent disability rating for hypothyroidism with hyperthyroidism (diagnosed as Grave's disease) have been most nearly approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.119, Diagnostic Codes 7900 and 7903. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty military service from August 1989 to November 1991, including service in Southwest Asia. Disability rating for hypothyroidism with hyperthyroidism The Veteran seeks a disability rating higher than 10 percent for her Grave's disease, rated by analogy as hypothyroidism with hyperthyroidism. There is no diagnostic code assigned specifically for Grave's disease, which in the Veteran's case has resulted in an unstable presentation of thyroid dysfunction, meaning that its primary manifestations of hypothyroidism and hyperthyroidism must both be considered. 38 C.F.R. § 4.20. Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.20. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Hyperthyroidism (overproduction of thyroid hormones) is rated under Diagnostic Code 7900, which provides for a 10 percent disability rating based on hyperthyroidism with tachycardia, which may be intermittent, and tremor, or a need for continuous medication to control the symptoms. 38 C.F.R. § 4.119. All higher disability ratings under Diagnostic Code 7900 include tachycardia as part of the disability picture. Because the Veteran does not have tachycardia or any other cardiovascular manifestation of hyperthyroidism, a higher rating under Diagnostic Code 7900 is not warranted. Hypothyroidism (underproduction of thyroid hormones) is rated under Diagnostic Code 7903, which provides for a 10 percent disability rating based on hypothyroidism with fatigability or a need for continuous medication to control the symptoms. 38 C.F.R. § 4.119. A 30 percent disability rating is assigned for hypothyroidism with fatigability, constipation, and mental sluggishness. Hypothyroidism with muscular weakness, mental disturbance, and weight gain is rated 60 percent disabling. Hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness is rated 100 percent disabling. In the Veteran's particular situation, many of the symptoms that are contemplated in the rating criteria related to thyroid dysfunction are also part of the criteria for other rated disabilities. These symptoms include depression, constipation, and muscle weakness which are, respectively, rated as part of the disabilities of depression, irritable bowel syndrome with constipation, and chronic fatigue syndrome with constipation. The law specifies that pyramiding, or the consideration of a set of symptoms under more than one diagnosis, is not permitted. 38 C.F.R. § 4.14. This makes determination of the correct disability rating for the Veteran's situation challenging. In order for the Board to consider the symptoms not already contemplated in other ratings, a review of those other ratings is necessary. The rating decision issued in March 2013 assigned the initial 10 percent rating for Grave's disease based on the need for continuous medication, as well as ratings for irritable bowel syndrome and chronic fatigue. The rating of 30 percent for irritable bowel syndrome was assigned based on manifestations of abdominal distress, alternating constipation and diarrhea, diarrhea, and frequent episodes of bowel disturbance. Chronic fatigue syndrome was rated as 60 percent disabling based on findings of symptoms of debilitating fatigue, generalized muscle aches and weakness, headaches, migratory joint pain, and irritable bowel syndrome. The headaches and irritable bowel syndrome were separately rated and not considered in the assigned 60 percent rating for chronic fatigue with fibromyalgia. Symptoms of hypothyroidism that are shown in the Veteran's medical records and which she testified to at the February 2021 Board hearing include: extreme cold intolerance which has necessitated moving across the country to a warmer climate, weight gain, fatigue, mental sluggishness, depression, weakness in her arms which limits her ability to care for herself, constipation, and sleepiness. In her Notice of Disagreement filed in March 2017, the Veteran asserted that her cold intolerance was severe enough that she had to wear a coat indoors. She also struggled with communicating people and difficulty sleeping, both of which she attributed to her thyroid dysfunction. She was continuing to gain weight despite her best efforts. At the VA examination in January 2016, the Veteran was noted to have undergone a thyroid ablation in 1993 after the sudden onset of tachycardia and Grave's disease. Her thyroid function had been very unstable ever since with large swings between hypothyroid and hyperthyroid. As a result, her constipation and IBS were significantly impacted; her chronic fatigue syndrome was the result of the damage to her thyroid. The examiner noted that the symptoms of IBS/constipation and chronic fatigue were inextricably intertwined with her thyroid dysfunction and could not be separated. The examiner listed the Veteran's symptoms as: gastrointestinal symptoms, palpitations, sympathetic nervous system symptoms, a need for continuous thyroid medication, fatigability, increased sweating, flushing, heat intolerance, and frequent bowel movements. Her fatigue was severe enough that she was unable to complete household chores. She had also had a weight gain of 5 pounds in the previous two weeks. She also suffered from cold intolerance. She was unable to work more than at a sedentary job for more than one hour at a time because of her fatigue and could not perform any strenuous tasks. Considering the symptoms that the Veteran experiences that are not already considered in rating associated disabilities, the Board finds that the Veteran's disability picture most nearly approximates the 60 percent disability rating criteria for hypothyroidism. The Board notes that these criteria specify muscle weakness, mental disturbance, and weight gain as required for a 60 percent rating, and that muscle weakness is already contemplated in the rating for chronic fatigue syndrome with fibromyalgia. However, the Veteran also suffers from some of the symptoms listed in the 100 percent rating criteria, particularly cold intolerance, and sleepiness. While the Veteran does not have cardiovascular involvement or bradycardia, which are also included in the 100 percent criteria, the manifestation of some symptoms from this rating is sufficient to compensate for the fact that the 60 percent criteria are not fully satisfied. As noted, the Board's finding that a 60 percent disability rating is warranted here is based on the more nearly approximated principle of rating of 38 C.F.R. § 4.7. Application of that principle is particularly warranted here because of the overlap of symptoms related to thyroid dysfunction in other disabilities for which the Veteran receives compensation. Use of the more nearly approximated principle also signifies that the criteria for a 100 percent disability rating are not met in this case. In particular, cardiovascular involvement relative to the Veteran's thyroid dysfunction has not been shown on VA examination or consistently throughout the Veteran's treatment. There is evidence that the Veteran had tachycardia at the time of her diagnosis with Grave's disease and the Veteran had a brief period of tachycardic episodes in 2013. However, the Veteran's findings on cardiac stress test were negative and no specific cardiovascular issues were found. Without any evidence of a cardiovascular impact from the Veteran's thyroid dysfunction, a 100 percent disability rating is not warranted. And without evidence of significant tachycardia, rating the Veteran's disability under Diagnostic Code 7900 for hyperthyroidism would not be of any benefit to her. For these reasons, a disability rating of 60 percent for hypothyroidism, and no higher, is granted. 38 C.F.R. § 4.119. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cheryl E. Handy 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.