Citation Nr: 0003550 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 96-43 371 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased evaluation for bilateral varicose veins, rated 30 percent disabling prior to January 12, 1998, and 40 percent disabling effective January 12, 1998. ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran had active service from December 1939 to October 1945. By rating action dated in September 1995, the Department of Veterans Affairs (VA) Regional Office, Chicago, Illinois, confirmed and continued a 30 percent evaluation for the veteran's bilateral varicose veins. He appealed from that decision. The case was initially before the Board of Veterans' Appeals (Board) in July 1998, when it was remanded so that the claim could be reviewed by the regional office with regard to the amendments to the VA rating schedule for rating disabilities regarding the cardiovascular system, including varicose veins, that became effective January 12, 1998. In a December 1998 rating action, the regional office confirmed and continued the 30 percent evaluation that was in effect for the bilateral varicose veins prior to January 12, 1998. Effective January 12, 1998, the regional office granted separate 20 percent evaluations for varicose veins of the right lower extremity and varicose veins of the left lower extremity, with a combined rating for the bilateral varicose veins of 40 percent. The case is again before the Board for further appellate consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the regional office. 2. The varicose veins of the veteran's right lower extremity measure about 1 centimeter in diameter; there is some slight sacculation. 3. The varicose veins of the left lower extremity are about 1 millimeter in size with tortuosity, and extend to the medial aspect of the thigh with the greater saphenous-type distribution. 4. The evidence does not show marked distortion and sacculation or episodes of ulceration prior to January 1998 or stasis pigmentation or eczema after January 1998. CONCLUSIONS OF LAW 1. An evaluation in excess of 30 percent for the veteran's bilateral varicose veins prior to January 12, 1998, is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Code 7120 (effective prior to January 12, 1998). 2. Evaluations in excess of 20 percent each for varicose veins of the right lower extremity and left lower extremity with a combined rating of 40 percent, effective January 12, 1998, are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Code 7120 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that it has found the veteran's claim to be "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); effective on and after September 1, 1989. That is, the Board finds that he has presented a claim which is plausible. The Board is also satisfied that all relevant facts regarding the claim have been properly developed. I. Background The veteran's service medical records reflect that he was hospitalized and treated during July and August 1942 for varicose veins of the left leg and thigh. Ligation of the varicose veins was performed. By rating action dated in April 1946 service connection was granted for varicose veins of the left leg, rated noncompensable. The veteran was hospitalized by the VA during June and July 1950 for a left inguinal hernia. The hernia was repaired in June 1950. While hospitalized it was noted that there was a scar of a sapheno-femoral ligation on the left, and there were several sacculated varicosities of the greater and lesser saphenous veins on the left. By rating action dated in July 1950 the evaluation for the varicose veins of the veteran's left leg was increased to 10 percent under Diagnostic Code 7120. In an October 1953 statement Phillip H. Best, M.D., indicated that the veteran had been examined in September 1953, and had severe varicose veins of the left leg involving the greater and superficial saphenous veins extending up to the mid thigh. The veteran complained of pain in the leg and thigh, and ankle edema was present. The veteran was examined by the VA in November 1953. He complained of swelling of his left leg and soreness of the upper left thigh. On examination there were moderately severe varicose veins, tortuous and sacculated, of the left thigh, left calf, and left leg. There were no varicose veins on the right thigh. There was a scar on the upper left thigh said to be the result of saphenous vein ligation. The scar was well healed, nontender, nonadherent, and nonfibrotic. The diagnoses included mild varicose veins of the right upper leg, and moderately severe varicose veins of the left leg and thigh that were sacculated and tortuous. By rating action dated in December 1953 the grant of service connection was expanded to include bilateral varicose veins. A 30 percent evaluation was assigned for the bilateral varicose veins under Diagnostic Code 7120. The veteran was again examined by the VA in November 1954. Various findings were recorded on physical examination. The diagnoses included varicose veins of the left thigh and left leg, moderate in nature, and minimal varicose veins of the right leg. By rating dated in January 1955 the evaluation for the varicose veins was reduced from 30 percent to 20 percent. In a January 1955 statement, Dr. Best referred to his previous letter of October 1953, which he enclosed. He stated that he saw the veteran at frequent intervals and there had been no improvement in his condition. He stated that the varicosities were progressively larger and involved the feet as well as the veins. The ankle edema was worse, and the veteran complained of more pain. He felt that there had been a deterioration in the veteran's condition. The veteran was again examined by the VA in November 1956. On the medial aspect of the lower third of the left thigh there was group of moderately enlarged and tortuous superficial veins. There were moderate localized and tortuous superficial varices on the medial and posteromedial aspects of the upper half of the left leg, and some moderate varices along the medial aspect of the left foot. There were mild superficial varices on the anterior aspect of the upper half of the left leg, and mild to moderate superficial varices on the posterior aspect of the lower half of the leg. There was no evidence of any varicosity of the right thigh. There was one small superficial varix over the junction of the middle and upper thirds of the right leg. There was no varicose pigmentation or stasis dermatitis, and no swelling, edema, or evidence of ulceration of either lower extremity. The veteran was hospitalized by the VA from March to June 1959. In April 1959 ligation and stripping of the greater saphenous vein and varices of the left lower extremity was performed. In a December 1959 statement, Arthur L. Ennis, M.D., indicated that the veteran complained of numbness of his left leg since his previous operation. The leg and thigh had felt better since the operation. Examination of the extremities showed slight varicose veins on the right leg and thigh, and slight varicose veins on the left leg with numerous operative scars. The veteran was again hospitalized by the VA during February and March 1978. Vein ligation and stripping of the left leg was performed. The veteran was examined by the VA in January 1985. There were varicosities of the left thigh measuring about 1 centimeter in diameter, which became mildly tortuous as they approached the knee. The left leg showed some varicosities that measured 5 to 8 millimeters in diameter with mild tortuosity. There were no varicose veins in the right thigh, but below the knee there were a few mild varicosities measuring 7 millimeters to 1 centimeter in diameter. There was one saccular area measuring about 3 1/2 centimeters in diameter on the posterior left calf. The deep veins appeared to be intact. There was no pigmentation. There was no scarring from ulcerations, and no active skin lesions. In a March 1985 rating action the evaluation for the bilateral varicose veins was increased from 20 percent to 30 percent. The veteran was examined by the VA in October 1993. He stated that he did not have any pain in his legs, and they did not swell. He stated that the only problem he had was that the left foot felt cold on occasion. On examination the veteran ambulated in a normal manner. In a standing position he had some varicosities in both lower extremities. On the right leg there were two dilated areas of about 12 millimeters in diameter. There was lesser saphenous distribution tortuosity. The vessels only measured about 7 to 8 millimeters in diameter. On the left lower extremity there were varicosities on the inner aspect of the leg and greater saphenous distribution, beginning up in the thigh area. Those were somewhat tortuous but not very large, and did not measure more than about 8 millimeters in size. The skin was in very good condition. It was soft and supple. Hair growth was normal. There were no callosities found. Both feet were warm to touch, and no paresthesias were found. The peripheral pulses were intact, but not very strong. The diagnoses included bilateral varicose veins involving the lower extremities. In April 1995 the veteran submitted a claim for an increased rating for the bilateral varicose veins. The veteran was afforded a VA examination in June 1995. He reported that his left lower extremity from the knee down felt cooler than it used to, and that both feet felt a little cool. He stated that he was not having any pain. He stated that he could walk two blocks without any problems. He denied having any claudication. He related that he used to wear elastic hose when he was working, but he had stopped working in 1980 and had not worn them since that time. He stated that he took no medication of any type. On examination his height was 71 1/2 inches and his weight 180 pounds. He ambulated in a normal manner. He had varicosities in his lower extremities. That was noticeable anteriorly on the right side. On the left side the veins were a little more posterior, and on up into the medial aspect of the thigh with a greater saphenous distribution. The vessels measured about 8 millimeters in diameter over the legs on the left side that extended up to the groin. On the right anterior leg there was an area that was sacculated. It measured about 1 1/2 centimeters by 12 millimeters. No paresthesia was found. The peripheral pulses were intact, but were not really strong. The left foot felt slightly cool compared to the right, but not really cold. The skin was in good condition. Hair growth was essentially normal. The examiner commented that he did not find much change in that examination from the 1993 examination. The diagnoses included bilateral varicose veins of the lower extremities. In a July 1996 statement Dhirendra Patel, M.D., indicated that the veteran had a long-standing history of varicose veins that seemed to be causing edema in both lower extremities since he had been admitted to a nursing home. It was indicated that at the current time he was being treated with knee high TED stockings and Lasix that seemed to help him keep it under control. A statement by W. B. Franklin, M.D., dated in July 1996, reflected that the veteran had venous varicosities. He indicated that apparently the veteran was having difficulty with more edema, since he had experienced a rather substantial intracerebral hemorrhage. In an October 1996 statement Dr. Patel indicated that the veteran had severe Parkinsonism, with senile dementia and a history of a stroke. He had been in a nursing home for almost one year. He was wheelchair bound and required total care for his activities of daily living. He had some swelling in his legs. He was taking medication for his Parkinsonism, and his restlessness and a diuretic for his swelling of the lower extremities. He was not able to ambulate without assistance, and then for only a very short distance. The veteran was examined by the VA later in October 1996. His wife indicated that in September 1995 he had had a stroke followed by a craniotomy. After returning home his legs began swelling more and more. He had been returned to the hospital and while there had another stroke. He was currently in a nursing home, and was able to walk in the halls of the nursing home with no problems. He had to wear elastic supports, and if he did not wear them both legs began swelling in a very short time. On examination the veteran ambulated very slowly, with a stooped posture. He was wearing elastic supports on both lower extremities. On removing those, the skin was in good condition and warm to touch down to and including the feet. There were varicosities on both lower extremities. On the right side they seemed to be more anterior and measured about 1 centimeter in diameter. There was some slight sacculation, with the largest being about 15 millimeters by 12 millimeters. The left lower extremity showed varicosities of about 1 millimeter in size, with tortuosity extending on up the medial aspect of the thigh with greater saphenous type distribution. There was no edema at the current time, but the examiner noted that the elastic supports had just been removed. The diagnoses were bilateral varicose veins of the lower extremities, and status post venous stripping of the left lower extremity. The regional office later received reports of the veteran's treatment from 1992 to 1995 for various conditions. The records included numerous laboratory reports and X-ray studies, as well as CT scans of the head. The regional office also received VA outpatient treatment records dated in October 1996 reflecting that the veteran was seen for an arterial and venous study of his legs. A venous Doppler of the legs showed there was good augmentation throughout both legs. There was venous reflux present in the right popliteal and right posterior tibial veins, and also reflux in the left femoral vein. The study was negative for deep venous thrombosis of both legs. Another study showed there was no thrombus seen on imaging, and all veins compressed easily throughout both legs. II. Analysis A 30 percent evaluation is warranted for moderately severe bilateral varicose veins involving the superficial veins above and below the knees with involvement of the long saphenous veins, varicosities ranging in size from 1 to 2 centimeters in diameter, and symptoms of pain or cramping on exertion but with no involvement of the deep circulation. Severe varicosities below the knees with ulceration, scarring, or discoloration and painful symptoms are also evaluated at the 30 percent level as moderately severe varicose veins. A 50 percent evaluation requires severe bilateral varicose veins involving the superficial veins above and below the knees with involvement of the long saphenous veins, varicosities ranging over 2 centimeters in diameter, marked distortion and sacculation, edema, and episodes of ulceration but with no involvement of the deep circulation. 38 C.F.R. Part 4, Code 7120, effective prior to January 12, 1998. A 20 percent evaluation is provided for varicose veins when there is persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent evaluation is provided when there is persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. 38 C.F.R. Part 4, Code 7120 effective January 12, 1998. The above evaluations are for involvement of a single extremity. If more than one extremity is involved, evaluate each extremity separately and combine, using the bilateral factor if applicable. Note under 38 C.F.R. Part 4, Code 7120, effective January 12, 1998. In this case, the record reflects that the veteran has varicose veins involving the right lower extremity which measure about 1 centimeter in diameter and which are slightly sacculated. The varicose veins of the left lower extremity are about 1 millimeter in size, with tortuosity and extend up to the medial aspect of the thigh with the greater saphenous- type distribution. The veteran has also reported swelling of the lower extremities soon after he removes his elastic supports. However, the record does not reflect that the varicose veins are over 2 centimeters in diameter with marked distortion and sacculation and with episodes of ulceration. Thus, the criteria for an evaluation in excess of 30 percent for the veteran's bilateral varicose veins under the provisions of Diagnostic Code 7120 that were in effect prior to January 12, 1998, have not been met. There has been no indication of stasis pigmentation or eczema on the VA examinations or private medical reports, and in fact on the June 1995 and October 1996 VA examinations, the skin was described as in good condition. Accordingly, under the circumstances, the requirements for evaluations in excess of 20 percent each for the varicose veins of the left and right lower extremities under the provisions of Diagnostic Code 7120 that were effective on January 12, 1998, have not been met. Although the bilateral factor has been considered, that factor (3.6 percent) would not result in a combined rating for the varicose veins of the left and right lower extremity in excess of 40 percent. See 38 C.F.R. § 4.26 (1999). Accordingly, under the circumstances, an evidentiary basis that would warrant allowance of the benefits sought on appeal has not been established. The Board has carefully reviewed the entire record in this case; however, the Board does not find the evidence to be so evenly balanced that there is doubt as to any material issue. 38 U.S.C.A. § 5107. ORDER An increased evaluation for bilateral varicose veins prior to January 12, 1998, is denied. An increased evaluation for bilateral varicose veins, effective January 12, 1998, is denied. WILLIAM W. BERG Acting Member, Board of Veterans' Appeals