Citation Nr: 21040673 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 18-32 209 DATE: July 6, 2021 ORDER Entitlement to an evaluation in excess of 20 percent for service-connected chronic idiopathic anhidrosis (CIA), including intermittent overheating, lack of sweating, headaches, fatigue, palpitations, and skin rash is denied. Entitlement to a separate evaluation of 10 percent, and no higher, for headaches associated with the Veteran's service-connected CIA for the entire period of time on appeal is granted. FINDING OF FACT The Veteran service-connected CIA is manifested by intermittent overheating, lack of sweating, headaches, fatigue, palpitations, and skin rashes. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating greater than 20 percent for service-connected CIA, including intermittent overheating, lack of sweating, headaches, fatigue, palpitations, and skin rash have not been met. 38 U.S.C. § 1155 (2019); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.88b, Diagnostic Code 6354 (2020). 2. The criteria for a separate rating of 10 percent, and no higher, for headaches related to the Veteran's service-connected CIA have been met for the entire period of time on appeal. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124A, Diagnostic Code 8100 (2020). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from July 2009 to March 2013. The Veteran presented sworn testimony before the undersigned Veterans Law Judge during a January 2021 hearing. A transcript has been associated with the claims file. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Neither the Veteran nor his representative has raised any issues with the duty to notify, the duty to assist, or the conduct of his January 2021 Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist or Bryant hearing deficiency argument). Thus, the Board need not discuss any potential issues in this regard. In reviewing the Veteran's appeal for an increased rating, the Board has not overlooked the holding of Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total disability rating based on individual unemployability (TDIU) can be inferred as part of the original claim for an increased rating in certain circumstances. In this case, however, the Veteran has not asserted that he is unemployable, and he maintains employment as a barber. As such, the Board finds that Rice is not applicable to this appeal and the current decision need not address the issue of entitlement to a TDIU. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Veteran asserts that his service-connected CIA, including intermittent overheating, lack of sweating, headaches, fatigue, palpitations, and skin rash warrants a rating greater than 20 percent. The Board notes that this disability has been rated under Diagnostic Codes 8911-6354. As an initial matter, the Board notes that the VA schedule for rating service-connected disabilities does not contain a specific diagnostic code created to evaluate anhidrosis. As such, VA has evaluated this service-connected disability by analogy to other diagnostic criteria. In this regard, the Board notes that Diagnostic Code 8911 evaluates epilepsy, petit mal. However, as the Veteran's service-connected disability does not manifest with episodes similar to seizures, nor does he take medication for his service-connected disability that would be similar to medications taken for seizures, the Board finds that evaluating the Veteran's disability under this diagnostic code is not appropriate. Under Diagnostic Code 6354, for chronic fatigue syndrome (CFS), a 10 percent rating is warranted for symptoms which wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year, or symptoms controlled by continuous medication. A higher 20 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, or which wax and wane resulting in periods of incapacitation of at least two but less than four weeks total duration per year. A 40 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities to 50 to 75 percent of pre-illness level, or which wax and wane resulting in periods of incapacitation at least four but less than six weeks per year. A 60 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or which wax and wane resulting in periods of incapacitation of at least six weeks total duration per year. Finally, a total disability rating is warranted for symptoms which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. A note under this regulation provides that the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. 38 C.F.R. § 4.88b, Diagnostic Code 6354. In evaluating this claim, the Board has reviewed all pertinent medical evidence of record, as well as the Veteran's statements and hearing testimony. Specifically, the Veteran testified at the January 2021 hearing that his condition causes him to overheat and to swell to the point where his skin is stretching. He reported cramps, weakness, migraines, skin rashes, heart palpitations, and fatigue. He reported that his headaches are prostrating and require him to close his eyes in a dark room. He reported related episodes occurring about once per week. The Veteran was afforded pertinent VA examinations in June 2017. In a June 2017 VA Seizure Disorder Disability Benefits Questionnaire (DBQ), the Veteran was noted as having CID. No diagnosis of seizure disorder or epilepsy disorder was noted. The Veteran reported his primary symptoms are headaches and rashes. He reported he gets headaches, especially when he gets overheated. His sister, who is a nurse, had advised him that he gets the rashes because his sweat glands do not work. He reported ongoing symptoms with no specific change over time. He denied cramping or muscle spasm. The examiner noted that there has been no acute heat exhaustion or heatstroke since 2012. He denied further specialty care since his initial evaluation and diagnosis made at Mayo Clinic in 2012. He reported no specific treatment but tries to stay out of the heat and avoids overworking his body. He is currently working as a barber in a climate-controlled environment. The examiner noted that he had a history of CID with intermittent symptoms. No specific treatment for his headaches was indicated. Examination revealed a normal skin examination except for 3 small areas of pinkness, likely unresolved or recurrent superficial bacterial infection. In a June 2017 VA Headaches DBQ, the Veteran reported that he will get a headache if he gets hot. He reported pain on the left side of the head, pointing to frontal area. The pain is throbbing. Sometimes, he gets dizzy and nauseated. He will get blurry vision. He will get these headaches every time he heats up, usually once or twice a week, more frequently during the summer temperatures. He will self-treat by sitting down and cooling off. He reported headaches could last up to 3 days. He does not take any medication for these headaches. It was noted that he did not have characteristic prostrating attacks of migraines/non-migraine headache pain. In a June 2017 VA Skin Diseases DBQ, it was noted that the Veteran reported skin rashes as a symptom of his CID. He was recently evaluated in a clinic by dermatology tele-consult and was diagnosed with a rash of infectious origin. He was treated with Clindamycin. He reported at this examination that spots remain on his left thigh. The examiner noted that there is no indication per medical record review or physical examination that this condition is incurred in or caused by the history of CID. The examiner noted that the Veteran's skin conditions did not cause scarring and did not result in systemic manifestations. It was noted that he took Clindamycin for less than 6 weeks in the previous 12 months. It was noted that the infections of the skins did not affect the exposed area of the skin and affected less than 5 percent of the total body area. Examination revealed 3 discrete, small, superficial erythema lesions with no central pustule, no fluctuance or induration, and no warmth. They were not follicular. The lesions were on the left thigh area and ranged in diameter from 1 to 2 centimeters. In a January 6, 2017, VA treatment record, the Veteran complained of an itchy/painful rash to his torso and extremities that began about a month ago. His symptoms included itching, pain, redness, and ulceration. He was prescribed Clindamycin. The Veteran also complained of a rash in a December 2016 VA treatment record. In a September 2016 VA treatment record, the Veteran reported generalized body ache, joint pains, and fatigue. He reported that he overheated from his CID. In August 2016, the Veteran complained of chronic joint pain, fatigue, loss of energy, and headaches. In consideration of the medical and lay evidence of record, the Board finds that a rating in excess of 20 percent is not warranted for this service-connected disability under Diagnostic Code 6354. The Board notes that, at the hearing, the Veteran reported that he gets headaches that require him to close his eyes in a dark room about once per week. However, there is no evidence reflecting that this disability has manifested during the period of time on appeal with symptoms which are nearly constant and restrict routine daily activities to 75 percent or less of pre-illness level, which wax and wane resulting in periods of incapacitation at least four weeks per year, or which may occasionally preclude self-care. No evidence from this time period reflects that the Veteran has been prescribed bedrest by a physician. The June 2017 DBQ noted that he maintained employment as a barber. It was further noted that his condition impacted his employment in that he needed to exercise caution not to overheat in a hot environment and needed to work in a climate-controlled environment. However, there was no indication that his routine was restricted to 75 percent or less of his pre-illness level. As such, the Board finds that an increased rating is not warranted for this disability under Diagnostic Code 6354 for any period of time on appeal. However, the Board has considered whether it would be appropriate to evaluate the symptoms related to the Veteran's service-connected disability under any other diagnostic codes. With regard specifically to the Veteran's reported rash or skin symptoms, the Board notes that a January 6, 2017, VA treatment record reflected that the Veteran was prescribed Clindamycin for a rash. It was also noted that he was prescribed Bactrim and Prednisone at an emergency room on December 20, 2016. However, the VA provider stated that he "personally would hold prednisone." While the Board has considered the Veteran's complaints related to his skin and does not deny that the Veteran's CID results in skin symptoms, the Board ultimately finds that the criteria for a separate evaluation for these skin complaints is not warranted under the schedule for rating disabilities of the skin. 38 C.F.R. § 4.118. Specifically, this disability has not resulted in scarring. The June 2017 VA examiner noted that the infections of the skin did not affect the exposed area of the skin and affected less than 5 percent of the total body area. Moreover, the Veteran has not required the use of medication consistently for these complaints. While he was apparently prescribed Prednisone at an emergency room visit on December 20, 2016, the VA provider who treated the Veteran on January 6, 2017, indicated that Prednisone was not recommended and prescribed the Veteran an antibiotic instead. Moreover, the Board notes that the Veteran testified at the January 2021 hearing that he was not receiving treatment for his condition. As such, the Board does not find the evidence of record warrants the assignment of a separate compensable evaluation for disabilities related to the skin, in light of the lack of scarring, the percentage of the body that the rash affected, and the fact that the Veteran was only prescribed Prednisone for a short time before a VA dermatologist apparently determined this was not the correct course of treatment. 38 C.F.R. § 4.118 (2017) (2020). With regard to the Veteran's headache complaints, the Board notes that the Veteran has reported that he experiences headaches when he gets overheated related to his service-connected CID. In the June 2017 VA Headaches DBQ, it was noted that the Veteran will get headaches once or twice a week. He will self-treat by sitting down and cooling. He reported the headaches can last up to 3 days. He does not take medication for the headaches. At the January 2021 hearing, the Veteran reported that his headaches are prostrating and require him to close his eyes in a dark room. He reported these episodes occur about once per week. Migraine headaches are evaluated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under this Code, a 0 percent disability rating is assigned for less frequent attacks. A 10 percent disability evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In light of the Veteran's above-described complaints regarding his headaches, the Board finds that a separate evaluation of 10 percent should be assigned under Diagnostic Code 8100 for the entire period of time on appeal. The Board has considered whether an evaluation in excess of 10 percent is warranted under Diagnostic Code 8100 based on the Veteran's headache complaints. As noted above, the Board has considered the Veteran's testimony at the January 2021 hearing that he has migraines that are prostrating and require him to close his eyes in a dark room. He testified that he had to leave early from work or call out of work for a day or two on occasion when he gets headaches. However, upon review of all evidence of record, the Board finds the evidence of record does not demonstrate that the Veteran's service-connected disability manifests with migraine headaches with characteristic prostrating attacks occurring on an average of once a month or with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Notably, the June 2017 DBQ documented that the Veteran did not have characteristic prostrating attacks of migraine/non-migraine headache pain. He was prescribed no medications for his headaches, and the headaches did not impact his ability to work. The Veteran specifically testified at the January 2021 hearing that his condition had not gotten worse since the June 2017 DBQ examination and the symptoms had remained at a consistent level of severity. Therefore, as there is no medical evidence of record, to include the June 2017 DBQ report, reflecting that the Veteran's disability manifests with migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months or with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, the Board finds that the greater weight of evidence is against finding that the Veteran's service-connected disability meets the criteria of an evaluation in excess of 10 percent for any period of time on appeal under Diagnostic Code 8100. In summary, the Board finds that the Veteran's service-connected CIA, including intermittent overheating, lack of sweating, headaches, fatigue, palpitations, and skin rash does not warrant an evaluation in excess of 20 percent for any period of time on appeal. Separately, however, the Board finds that the evidence supports the assignment of an evaluation of 10 percent, and no higher, for the Veteran's related headaches for the entire period of time on appeal. Assignment of staged ratings has been considered and is not for application. Hart, supra. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Durham, 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.