Citation Nr: 21029390 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 17-24 920 DATE: May 13, 2021 ORDER A rating in excess of 10 percent for the service-connected hypothyroidism status post thyroidectomy is denied. A separate rating of 10 percent, but no higher, for pericarditis as a residual to the service-connected hypothyroidism status post thyroidectomy is granted, subject to the laws and regulations governing the award of monetary benefits. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's hypothyroidism has required continuous medication for control, but has not been manifest by marked neuromuscular excitability or paresthesia with increased intercranial pressure. 2. The Veteran's pericarditis as a residual of hypothyroidism status post thyroidectomy has been manifest by a workload of greater than 7 METs that resulted in fatigue and angina, with no evidence of cardiac hypertrophy, dilatation, left ventricular dysfunction, or any episodes of congestive heart failure. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the service-connected hypothyroidism status post thyroidectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code (DC) 7905. 2. The criteria for a separate rating of 10 percent, but no higher, for pericarditis as a residual of the service-connected hypothyroidism status post thyroidectomy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, DC 7002. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2000 to March 2009. This current matter comes before the Board of Veterans Appeals (Board) on appeal from an April 2015 rating decision. In December 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's claims file. In February 2020, the Board remanded this appeal further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran seeks an increased disability rating for her service-connected hypothyroidism status post thyroidectomy. Currently, her hypothyroidism is rated at 10 percent disabling under DC 7905. 38 C.F.R. § 4.119, DC 7905. Changes to the rating criteria for the endocrine system became effective December 10, 2017. Claims pending prior to the effective date will be considered under both the old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. 82 Fed. Reg. 50802 (November 2, 2017). As the current matter has been on appeal since April 2015, it must be considered under both the old and new criteria. Pursuant to the old criteria for DC 7905, a 10 percent rating is warranted for hypothyroidism for continuous medication required for control. A 60 percent rating is warranted for marked neuromuscular excitability; or paresthesias (of arms, legs or circumoral area) plus either cataract or evidence of increased intracranial pressure. A 100 percent rating is warranted under the DC for marked neuromuscular excitability (such as convulsions, muscular spasms (tetany) or laryngeal stridor) plus either cataract or evidence of increased intracranial pressure (such as papilledema). Pursuant to the new rating criteria for DC 7905, a 100 percent rating is assigned for 3 months after the initial diagnosis. Thereafter, DC 7905 states that chronic residuals, such as nephrolithiasis (kidney stones), cataracts, decreased renal function, and congestive heart failure should be rated under the appropriate diagnostic codes. In April 2015, the Veteran was afforded a VA examination. The examiner noted that the Veteran had a thyroidectomy for papillary carcinoma in 2008 and has been on medications since the surgery. The Veteran reported that she has had trouble adjusting to her thyroid medications. She receives weekly medication injections and takes oral medication daily. She also reported experiencing fatigue and diarrhea and stated that her weight is somewhat fluctuant. Her physical examination was unremarkable. The examiner noted that her eyes were normal, with no exophthalmos, there were no palpable thyroid enlargements or nodules in her neck, her pulse was regular, and her reflexes were intact. The areas of skin on the Veteran's neck were not found to be hypo or hyperpigmented, to have abnormal texture, missing underlying soft tissue, or indurated and inflexible related to thyroid or parathyroid disease. Further, the examiner noted that there was no residual endocrine dysfunction following her thyroid condition. There were no findings, signs, or symptoms of a thyroid or parathyroid condition and no symptoms due to pressure on adjacent organs such as trachea, larynx, or esophageal attributable to a thyroid condition. The examiner reported that the Veteran's thyroid condition did not impact her ability to work. At the December 2019 hearing, the Veteran testified that she has never been diagnosed with kidney stones, decreased renal function, or any type of heart failure, but has been diagnosed with cataracts. Further, she testified that she still experiences fatigue, weight fluctuations, and diarrhea, as she has irritable bowel syndrome. She testified that she does not have any neuromuscular excitability or paresthesia and has never been diagnosed with increased cranial pressure. In October 2020, the Veteran was afforded another VA examination to assess the current severity of her thyroid disability and its residuals. The examiner confirmed the Veteran's diagnosis of hypothyroidism status post thyroidectomy and noted there was no change in diagnosis. Further, the examiner noted that she did not have any residual endocrine dysfunction following treatment for her thyroid condition. The physical examination revealed her eyes were normal, with no exophthalmos, her neck was normal, with no palpable thyroid enlargement or nodules, and her pulse was regular. However, the Veteran did report experiencing skin and reproductive symptoms attributable to a thyroid condition and the examiner noted that she does have a scar related to the treatment of her thyroid disability on her anterior neck. The examiner noted that the scar measures 12 by 0.1 centimeters and is not painful or unstable, there is no elevation, depression, adherence to underlying tissues, or missing underlying soft tissue found. Additionally, there was no abnormal pigmentation, texture, or gross distortion or asymmetry noted. There were no other residual conditions or pertinent physical findings related to her thyroid disability found. The Veteran reported that her thyroid disability does impact her ability to work, as it affects her attention and focus. During the examination, the examiner noted that the Veteran's medical records show she was diagnosed with renal insufficiency in 2013. However, she does not have any signs or symptoms of renal dysfunction and does not require dialysis or any other treatment for it. She does not have hypertension, renal tubular disorder, or frequent attacks of colic with infection. She has no history of urolithiasis, recurrent urinary tract or kidney infections, or a kidney transplant or removal. She does not have any benign or malignant neoplasms or metastases, or other pertinent physical findings related to renal dysfunction. Laboratory studies revealed her blood urea nitrogen (BUN) to be 11, creatinine 0.91, and estimated glomerular filtration rate (EGFR) 79; all within normal limits. The examiner reported the Veteran was well developed, well nourished, and in no acute distress. There were no signs of malaise present. He reported that there were no signs or symptoms to support a diagnosis of nephrolithiasis due to hypothyroidism status post thyroidectomy. The examiner did note that the Veteran had stage III chronic renal disease associated with the service-connected hypothyroidism status post thyroidectomy but noted that it was asymptomatic. Also, the examination revealed that the Veteran was diagnosed with pericarditis in August 2017, for which she takes daily medication. She is not currently being treated for an active infection, has not had a syphilitic aortic aneurysm, and does not have pericardial adhesions. She did have a cardiac catherization in 2017 due to elevated troponin levels but has not had any other hospitalizations or procedures for heart conditions. She has no history of myocardial infarction, congestive heart failure, cardiac arrhythmia, or a heart valve condition. Her physical examination was within normal limits, with a regular heart rate of 87, normal heart sounds, clear lungs, normal pulses, and no edema. There were no other pertinent physical findings or scars related to a heart condition. There was no evidence of cardiac hypertrophy or cardiac dilation and her electrocardiogram (EKG), chest X-ray, and echocardiogram were all normal. Exercise stress testing was not indicated for the Veteran, so she underwent an interview based metabolic equivalent test (METs) which found her METs level to be greater than 7-10 METs results in fatigue and angina. The examiner concluded that her pericarditis was at least as likely as not due to her service-connected hypothyroidism status post thyroidectomy, explaining that pericardial effusion is a rare, yet serious, complication of hypothyroidism that later develops into pericarditis. In January 2021, the Veteran was afforded a VA eye examination. She reported a history of cataract surgery in both eyes. The examiner confirmed diagnoses of bilateral pseudophakia status post cataract extraction and bilateral lattice degeneration. The Veteran reported experiencing some blurriness of vision in both eyes, but stated that she has prescription glasses to help both her near and far vision. She stated that there is no impact on her ability to perform any of her occupational duties or normal daily activities. Her visual acuity for uncorrected distance was 20/40 in the right eye and 20/50 for the left. Uncorrected near was 20/100 for both right and left eye. Corrected for both near and distance was 20/20 or better in both eyes. Both pupils were 4 millimeters, round, and reactive to light, with no pupillary defect present. Tonometry pressure was 20 in both eyes and there was no anatomical loss, light perception only, extremely poor vision, blindness, astigmatism, or diplopia found. A visual field defect was noted, showing contraction of a visual field, but no loss of a visual field or scotoma. The examiner reported that there was no ocular pathology noted that is associated with the service-connected hypothyroidism and no diabetic retinopathy was observed. Further, he stated that the visual field contraction was of undetermined etiology and that the lattice degeneration is a separate and unrelated condition to the pseudophakia and cataracts. Given the above, the Board finds that a rating in excess of 10 percent for hypothyroidism is not warranted, under either the old or new criteria for DC 7905. As noted above, under the old criteria, a 10 percent rating is warranted for hypothyroidism requiring continuous medication for control. The next higher rating is 60 percent, which requires marked neuromuscular excitability or paresthesia, plus evidence of increased intercranial pressure. The Veteran denied experiencing these symptoms during her testimony, and there was no evidence of any of these symptoms during either the April 2015 or the October 2020 VA examination. However, the Veteran does require continuous medication to control her hypothyroidism. Thus, a continued rating of 10 percent is warranted. Under the new criteria, a 100 percent rating is assigned for 3 months after the initial diagnosis. Unfortunately, this would not apply to the Veteran, as she was diagnosed with hypothyroidism in 2009, 8 years before the new criteria went into effect. However, the new criteria do allow for chronic residuals of hypothyroidism to be rated separately under the appropriate DC. In this regard, the Board finds that a separate compensable rating under DC 7002, for pericarditis as a residual to the service-connected hypothyroidism status post thyroidectomy, is warranted. Under DC 7002, a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on EKG, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or a workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7002. At the October 2020 VA examination, the Veteran's METs level was found to be greater than 7 to 10 METs. At no point during the appeal period has her METs level been found to be less than 7 METs, nor has there been any evidence of cardiac hypertrophy or dilation, any episodes of congestive heart failure, or left ventricular dysfunction. Thus, a separate compensable rating of 10 percent, but no higher, is warranted for pericarditis as a residual to the service-connected hypothyroidism from August 2017. The October 2020 VA examination also found that the Veteran has stage 3a chronic renal disease and stated that it is likely related to her hypothyroidism as well. However, the examiner also noted that her renal disease is asymptomatic and does not currently require any treatment. According to 38 C.F.R. § 4.115b, renal disease is to be rated as renal dysfunction, under 38 C.F.R. § 4.115a. A non-compensable rating for renal dysfunction is warranted for albumin and casts with a history of acute nephritis or hypertension non-compensable under diagnostic code 7101. A 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema; or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or creatinine 4 to 8mg%; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; BUN more than 80mg%; creatinine more than 8mg%; or markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. As noted above, the Veteran's renal dysfunction is currently asymptomatic. There is no evidence that at any point during the appeal period she has had albumin or casts, acute nephritis, hypertension, edema, abnormal BUN or creatinine, generalized poor health, required dialysis, or decreased kidney or other organ functions. Thus, a compensable rating for renal dysfunction is not warranted. The October 2020 examiner noted that the Veteran reported experiencing reproductive symptoms and skin symptoms related to her hypothyroidism. The Board acknowledges that, as of October 8, 2020, the AOJ granted a noncompensable rating for female sexual arousal disorder associated with hypothyroidism status post thyroidectomy and for monilethrix associated with hypothyroidism status post thyroidectomy, under DCs 7632 and 7807 respectively. The Veteran has not raised the issue of entitlement to an increased rating for her service-connected female arousal disorder or monilethrix. Thus, neither of these issues are currently on appeal and will not be addressed further in this decision. The Board also acknowledges that the Veteran was granted a noncompensable rating for her surgical scar status post thyroidectomy under DC 7800 on April 1, 2009. Under DC 7800, a rating of 10 percent requires at least one characteristic of disfigurement. The 8 characteristics of disfigurement for evaluation purposes are: scar 5 or more inches (13 or more centimeters) in length; scar at least one-quarter inch (0.6 centimeters) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or-hyper pigmented in an area exceeding 6 square inches (39 square centimeters); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 square centimeters); underlying soft tissue missing in an area exceeding 6 square inches (39 square centimeters); skin indurated and inflexible in an area exceeding 6 square inches (39 square centimeters). 38 C.F.R. § 4.118, DC 7800, Note 1. Any rating greater than 10 percent requires visible or palpable tissue loss and either gross distortion or asymmetry of at least one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or two or more characteristics of disfigurement. 38 C.F.R. § 4.118, DC 7800. The Veteran's scar is 12 centimeters by 0.1 centimeters and is not painful or unstable. It does not meet any criteria for a characteristic of disfigurement, nor is there any visible or palpable tissue loss, gross distortion, or asymmetry. Thus, a compensable rating for her scar related to her thyroidectomy is not warranted. Lastly, the Veteran testified that she has been diagnosed with cataracts in both eyes. The Board acknowledges that she has been service-connected for left eye pseudophakia (previously rated as cataract of the left eye) since April 1, 2009. As of November 11, 2016, her left eye pseudophakia has been rated at 10 percent. The January 2021 VA examiner confirmed this diagnosis but noted that there was no ocular pathology associated with her hypothyroidism. In fact, the Veteran reported that her right eye cataract was diagnosed in either 2007 or 2008, prior to her thyroidectomy and subsequent hypothyroidism. Thus, her cataracts are not considered a residual of her hypothyroidism and will not be considered in this increased rating claim. Accordingly, the weight of the probative evidence of record demonstrates that a rating in excess of 10 percent for hypothyroidism status post thyroidectomy is not (CONTINUED ON NEXT PAGE) warranted. However, a separate compensable rating of 10 percent, but no higher, is warranted for pericarditis as a residual to hypothyroidism status post thyroidectomy. The claim for increased rating is granted to that extend only. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Benson, 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.