Citation Nr: 21028809 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-08 734 DATE: May 12, 2021 ORDER Entitlement to a 10 percent rating for granulomas as of February 14, 2014, is granted. FINDING OF FACT From February 12, 2014, the Veteran's service-connected granulomas were manifested by pre- and post-bronchodilator FEV-1/FVC scores of 75 percent. CONCLUSION OF LAW The criteria for a 10 percent rating for granulomas due to pneumonia as of February 12, 2014, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6600. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from March 1944 to January 1947. A hearing was conducted by Travel Board in March 2017 before the undersigned Veteran's Law Judge, at which the Veteran testified; a transcript is of record. A May 2019 Board decision denied a compensable rating for service-connected granulomas due to pneumonia prior to November 21, 2017, and, denied a rating in excess of 10 percent thereafter. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a January 2020 Order, based upon a Joint Motion for Partial Remand (JMPR), the Court vacated and remanded the part of the Board decision which denied a compensable rating prior to November 21, 2017. The remainder of the decision was not appealed. 1. Entitlement to a compensable rating for granulomas due to pneumonia prior to November 21, 2017. By way of history, the Veteran's lung granulomas were assigned a noncompensable rating under Diagnostic Code (DC) 6820-6600 since the effective date of service connection and a subsequent decision granted a 10 percent rating effective November 21, 2017. The Veteran now contends that a compensable rating was warranted prior to November 21, 2017. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). As a result, a complete medical history of the Veteran is required for a ratings evaluation. This is in order to protect claimants against adverse decisions based on a single, incomplete, or inaccurate report, and to enable VA to make a more precise evaluation. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, VA has a duty to acknowledge and consider all regulations which are potentially applicable, and to explain the reasons and bases for its conclusions. Respiratory disorders are rated under Codes 6600 through 6817 and 6822 through 6847. Ratings under those diagnostic codes will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96(a). Under these codes, a 10 percent rating is warranted for: Forced Expiratory Volume in one second (FEV-1) of 71-to 80-percent predicted, or; Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 66-to 80-percent predicted. A 30 percent rating is warranted for: FEV-1 of 56-to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) of 56-to 65-percent predicted. A VA examination in February 2012 confirmed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and lung granulomas. The Veteran was noted to use inhalational bronchodilator therapy and inhalational anti-inflammatory medication, both of which were predominantly necessary due to the Veteran's non-service connected COPD. The examiner did not perform a Pulmonary Function Test (PFT) at this time. A May 2012 addendum explanation was obtained from the examiner to explain why a PFT was not performed. The examiner indicated that the Veteran's granulomas were of a non-growing nature and that they were not known to cause respiratory impairment, and therefore, a PFT was not ordered. The Veteran was next seen for a VA examination in June 2014. The examiner identified COPD and granulomas of the lung as the respiratory conditions which the Veteran had at that time. The examiner indicated that the Veteran's granulomas of the lungs did not require the use of inhaled medications. At that time the Veteran's FVC pre-bronchodilator was 2.61 % and FVC post bronchodilator was 2.58%; FEV pre-bronchodilator was 1.95 % and post bronchodilator was 1.93 %; FEV-1/FVC pre-bronchodilator was 75% and post-bronchodilator was also 75%. DLCO was not applicable for the pre-bronchodilator and post bronchodilator was recorded as 19.9%. The examiner indicated that the DLCO score was most representative of the Veteran's level of disability. In November 2016, a supplemental opinion was obtained to clarify the results of the June 2014 PFT. The examiner who performed this test indicated that the granulomas were not responsible for the PFT scores as it does not result in alterations to PFT findings. Rather, the examiner explained, that the PFT results represented the effects of the Veteran's COPD. The examiner indicated that the entry stating that the DLCO score most accurately reflected his COPD status was entered in error. In January 2015 a medical opinion was requested regarding any increase in the severity of the Veteran's granulomatous lung disease. The examiner indicated that based on the medical evidence available at that time, the findings of the one PFT on record was compatible with COPD. However, the examiner indicated that she was unable to render a complete opinion regarding the what degree granulomas affected his results as there was only one incomplete PFT performed. The examiner recommended referring the Veteran for a further PFT study. In November 2017, the Veteran was seen for another VA examination. The Veteran was noted to use inhalational bronchodilator therapy which was predominantly for his COPD. The Veteran's PFT results were as follows: FVC pre-bronchodilator was 55% predicted and FVC post bronchodilator was 85% predicted; FEV-1 pre-bronchodilator was 54% predicted and post bronchodilator was 71% predicted; FEV-1/FVC pre-bronchodilator was 95 % predicted, post-bronchodilator results were not reported for FEV-1/FVC testing. The examiner did not perform DLCO testing at this exam as he found it was not indicated for the Veteran's condition. The examiner noted that the Veteran's granulomas were of a non-growing nature and granulomas are not known to cause significant respiratory impairment and there was no change in the lung granulomas diagnosis. Following that examination, the AOJ assigned a 10 percent rating based on the pulmonary findings. A May 2019 Board decision, in pertinent part, denied a compensable rating for service-connected granulomas due to pneumonia prior to November 21, 2017. As noted above, the Veteran appealed that decision to the Court. In the January 2020 JMPR, the parties agreed that the Board erred in determining that the Veteran was not entitled to a compensable rating for his service-connected granulomas due to pneumonia prior to November 21, 2017; based on a finding that his non-service-connected COPD caused his respiratory condition, and not his service-connected granulomas. The parties agreed that the prior VA examinations of record did not support such a conclusion. The parties noted that the February 2012 examiner did not provide an opinion as to whether the Veteran's decreased pulmonary function was caused by or the result of his service-connected granulomas. In the May 2012 addendum opinion, the examiner opined that the Veteran's granuloma did not cause his COPD, but did not opine as to whether his decreased pulmonary function was caused by or the result of his service-connected granulomas. In the June 2014 opinion, the examiner provided no opinion as to the cause of the Veteran's decreased pulmonary functioning. The parties also noted that the January 2015 examiner found that he could not opine as to the cause of the Veteran's decreased pulmonary function because the Veteran did not have a complete PFT. This matter was then before the Board in July 2020. The Board determined that a remand was necessary to obtain a medical opinion regarding the Veteran's decreased pulmonary functioning prior to November 21, 2017. Specifically, a medical opinion was requested to discuss the extent to which the Veteran's service-connected granulomas contributed to the Veteran's decreased pulmonary functioning, and to consider the degree to which the Veteran's non-service-connected COPD also contributed to the decreased pulmonary functioning prior to that date. The requested opinion was obtained in January 2021.The examiner opined that the Veteran's decreased pulmonary functioning was mainly affected by his pulmonary granulomas. As rationale, the examiner stated that the Veteran has had multiple pulmonary granulomas discovered in 1945 that are considered an interstitial lung disease leading to pulmonary fibrosis. The examiner added that this has been reflected on his PFT as low FVC and DLCO. The examiner cited a February 2014 PFT, which showed low FVC indicative of pulmonary fibrosis. Notably, the examiner stated that the Veteran's FEV1/FVC ratio of over 70% at the time of the February 2014 and November 2017 examinations does not support diagnosis of COPD. The Board finds that a 10 percent rating is warranted for the Veteran's granulomas as of February 12, 2014. While there is conflicting medical evidence of record as to whether the Veteran's decreased pulmonary functioning was related to his service-connected granulomas or non-service connected COPD prior to November 21, 2017, the Board resolves any reasonable doubt in the Veteran's favor and finds that his symptoms were related to the granulomas. As a determination in this case hinges on a finding that the Veteran's symptoms were not related to his non- service connected COPD, the Board finds it highly probative that the January 2021 examiner found that the Veteran did not have a diagnosis of COPD during the period on appeal. The PFT conducted on February 12, 2014, are the earliest pulmonary function findings in the medical evidence of record showing an FEV1/FVC ratio of 75%, meeting the criteria for a compensable 10 percent rating under Diagnostic Code 6600. To that extent, the January 2021 examiner also concluded that the PFT findings from February 2014 were mainly affected by the Veteran's service-connected pulmonary granulomas. Based on this, the Board finds that a 10 percent rating is warranted as of February 12, 2014. The Board has considered whether a compensable rating is warranted prior to February 12, 2014, but concludes that the evidence of record does not support such a finding. While the Veteran was noted to require inhalational bronchodilator therapy and inhalational anti-inflammatory medication at the time of the February 2012 examination, there are no PFT findings of record prior to February 2014 that show an FEV1/FVC ratio of 71 to 80 percent to warrant a compensable rating under Diagnostic Code 6600. No additional higher or alternative ratings under different Diagnostic Codes can be applied in this case. Notably, a January 2014 chest x-ray indicated that the Veteran had bilateral calcified pulmonary nodules. However, there is no evidence in either the examination reports or the treatment records that the Veteran has neoplasms of the lungs or that the nodules are malignancies. Further, even assuming that such nodules may be considered benign neoplasms of the lungs, benign neoplasm are to be rated by analogy to an appropriate respiratory disability. 38 C.F.R. § 4.97, Diagnostic Code 6820. All other disabilities based on restrictive lung diseases are rated based on the same criteria as the Veteran's granulomas, and thus higher ratings would not be possible based on the discussion above. 38 C.F.R. § 4.97, Diagnostic Codes 6601 to 6604, 6840 to 6845. As such, higher ratings under other Diagnostic Codes are not possible. Based on the foregoing, the Board finds that an increased 10 percent rating is warranted for the Veteran's service-connected granulomas as of February 12, 2014. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Marsh II, 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.