BVA9500804 DOCKET NO. 92-05 635 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased rating for thyrotoxicosis, currently evaluated as 10 percent disabling. ATTORNEY FOR THE BOARD Mark D. Hindin, Counsel INTRODUCTION The veteran had active service from July 1986 to July 1990. This matter arises from an April 1991, rating decision in which the regional office (RO) granted service connection for thyrotoxicosis, and established a 10 percent evaluation for that disability effective the day following discharge from service. In October 1992, the Board of Veterans' Appeals (the Board) remanded the case to the RO for efforts to obtain additional treatment records, to afford the veteran a Department of Veterans Affairs (VA) examination, and to consider her contentions regarding entitlement to a total rating for compensation purposes based on individual unemployability. That development has been completed. The RO denied entitlement to a total rating for compensation purposes based on individual unemployability in a rating decision dated in July 1993. The veteran has not appealed that decision. In a statement dated in September 1994, the veteran expressed disagreement with an April 1994 rating decision which had denied entitlement to service connection for the residuals of a lymph node excision. This issue has not been developed for appellate consideration and is referred to the RO for appropriate development. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that her thyroid disease causes easy fatigability, weight loss, increased thyroid hormone levels, and pronounced thyroid enlargement. She asserts that these symptoms meet the criteria for at least a 60 percent evaluation. She also asserts that she has Graves' disease, which is a severe form of thyrotoxicosis, and that she is therefor entitled to an increased rating. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence is in favor of the grant of a 30 percent rating for thyrotoxicosis. FINDINGS OF FACT 1. All evidence necessary for an equitable resolution of this case has been secured. 2. The veteran's thyrotoxicosis is manifested principally by a history of increased levels of circulating thyroid hormones, and some elevated blood pressure readings; and complaints of a racing heart; without any documented history of marked emotional instability, fatigability or tachycardia, or surgery, and is currently manifested by thyroid enlargement, fine tremors, mild anxiety, and complaints of exercise and heat intolerance without increased levels of circulating thyroid hormones. CONCLUSION OF LAW A 30 percent evaluation for thyrotoxicosis is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 7900 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. History The veteran's service medical records do not show findings of a thyroid disorder. On examination for entrance into service she weighed 134 pounds. In June 1988, she was reported to have blood pressure readings of 136/100, 152/120, and 142/110. Later in June 1988, diastolic blood pressure readings were reported to range from 80 to 100. An assessment of mild hypertension was reported. Her last reported weight during service was 126 1/2 pounds. The veteran was first found to have a thyroid disorder on treatment by a private physician in August 1990. She was initially seen with a complaint that she had not been "feeling well" for six months. She had been experiencing dizziness and difficulty standing with tingling in her legs and a feeling that her heart was racing. It was also reported that she had gained 10 pounds. She was found to have elevated T3 and T4 levels. A thyroid scan conducted later that month revealed findings consistent with Graves' disease. On VA examination in December 1990, the veteran complained of an inability to tolerate heat. She reported that she experienced excessive perspiration, muscle weakness and an inability to stand for prolonged periods. She also reported that she took medication to control heart palpitations. On examination she weighed 152 pounds. Her heart rate and rhythm were reported to be normal. Her pulse was 80, and her blood pressure was 104/82. A psychiatric and personality evaluation was within normal limits. Her T3 uptake was 24.5 percent with 25 to 37 percent being normal. Her T4 level was 13.5 with a level of 4.5 to 12.5 being normal. The diagnosis was thyrotoxicosis. During VA examination in June 1993, the veteran complained of tremors, heat intolerance, exercise intolerance, and a weight loss of seven pounds in six months. On examination her blood pressure was 140/90, and she weighed 138 pounds. She was described as well nourished and in no acute distress. She was mildly anxious. There was a minimal eyelid lag and staring appearance. Her thyroid was three times normal size. Her T3 and T4 levels were within normal limits. An electrocardiographic examination was within normal limits, and her pulse rate was 68. The diagnosis was active Graves' disease. Private treatment records dated from July 1992 to May 1994, show that the veteran's T3 and T4 levels were within normal limits on testing in July and September 1993, and that her T4 level was actually below normal in May 1994 while her T3 level was again within normal limits. In September 1993, she was noted to have a fine tremor most notable in the left hand. It was commented that her hyperthyroidism might still be "smoldering." II. Analysis The veteran has presented a well-grounded claim within the meaning of 38 U.S.C.A. § 5107. In this regard, she has submitted evidence in support of her claim which renders it plausible. The Board also finds that VA has complied with its obligation to assist her with the development of that claim under the same code provision. The veteran's thyroid disability is evaluated under the provisions of Diagnostic Code 7900; 38 C.F.R. § 4.119 (1993). Under that diagnostic code, hyperthyroidism warrants a 100 percent evaluation when it results in pronounced disability, with thyroid enlargement, severe tachycardia, increased levels of circulating thyroid hormones (T4 and/or T3, by specific assays), with marked nervous, cardiovascular or gastrointestinal symptoms; muscular weakness and loss of weight; or postoperative with poor results, and the pronounced symptoms persisting. A 60 percent evaluation is provided when the hyperthyroid disorder is severe, with marked emotional instability, fatigability, tachycardia and increased pulse pressure or blood pressure, and increased levels of circulating thyroid hormones. A 30 percent evaluation is for application where the disability is moderately severe, with a history as shown for the "severe" evaluation but with reduced current symptoms; or postoperative with tachycardia and increased blood pressure or pulse pressure of moderated degree with a tremor. Where the disability is moderate or postoperative with tachycardia, which may be intermittent, and tremor, a 10 percent evaluation is provided. In the veteran's case, although she has been reported to be anxious, and has complained of a racing heart, she has never been shown to have emotional instability, fatigability or tachycardia at a marked level. However, she has had a history of increased blood pressure and elevated circulating thyroid hormones. Currently the veteran has been noted to be somewhat anxious, to have a fine tremor, and to have complaints of exercise intolerance. She also has an enlarged thyroid. It can be said that the veteran has a history as shown under the criteria for "severe" with lesser current symptomatology. This history and findings most closely approximate the criteria for a 30 percent evaluation. Accordingly, an increased, 30 percent, evaluation is granted. The veteran does not currently have marked emotional instability, fatigability or tachycardia, and has not been shown to currently have increased pulse pressure or blood pressure or increased levels of T4 or T3. She has asserted that she has some of these symptoms, but they have not been demonstrated on examinations or during clinical treatment. She does not, therefore, meet the criteria for a 60 percent evaluation. The veteran has asserted that the recent finding of a below normal level of T4, could serve as a basis for an increased evaluation. However, as she has recognized, she is service connected for a hyperthyroid disorder. This disability is evaluated in part on the basis of increased circulating thyroid hormone levels. A decrease in those levels could not serve as a basis for an increased evaluation for a hyperthyroid disorder. She has also asserted that her diagnosis of Graves' disease shows that her hyper-thyroid condition is severe. The rating schedule does not recognize this logic. It bases evaluations on the objective symptomatology, as discussed above, rather than on whether a diagnosis of Graves' disease has been made. In reaching its conclusions in this case the Board has considered all of the provisions of Chapters 3 and 4 of 38 C.F.R. (1993). The Board has specifically considered the provisions of 38 C.F.R. § 3.321, pertaining to extra-schedular evaluations. However, the veteran's thyroid disability has not required frequent periods of hospitalization, or been shown to markedly interfere with employment, beyond the level contemplated by her current schedular evaluation. Accordingly, the Board has found that her disability picture, is not so unusual as to render impractical the application of the regular schedular criteria. The Board has also considered the provisions of 38 C.F.R. § 4.7, which provides for assignment of the next higher evaluation where the disability picture more closely approximates the criteria for the next higher evaluation. As discussed above, the veteran's disabilities most closely approximate the criteria for a 30 percent evaluation. The Board has been unable to find a basis under any other regulation, which would permit the allowance of an increased rating beyond 30 percent, for the veteran's service- connected thyroid disability. ORDER A 30 percent evaluation for thyrotoxicosis is granted subject to the laws and regulations governing the payment of monetary awards. U. R. POWELL Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.