Source: https://va-claim.com/2017/12/13/migraine-headaches-intervertebral-disc-syndrome-of-the-thoracic-and-lumbar-spine-ivds-left-lower-extremity-neurological-impairment-memory-impairment-due-to-undiagnosed-illness-and-tdiu-citation/
Timestamp: 2019-04-20 18:41:50+00:00

Document:
1. Entitlement to a disability rating in excess of 50 percent for migraine headaches.
2. Entitlement to a disability rating higher than 20 percent for intervertebral disc syndrome of the thoracic and lumbar spine (IVDS).
3. Entitlement to a disability rating higher than 20 percent for left lower extremity neurological impairment as a result of disc prolapse at L5-S1.
4. Entitlement to a disability rating higher than 10 percent for memory impairment due to undiagnosed illness.
5. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU).
The Veteran served on active duty from November 1988 to November 1991.
This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision.
These claims were all previously remanded by the Board in an August 2009 decision requesting additional development including medical examinations and opinions. The additional evidence has been completed and jurisdiction has returned to the Board.
Included in the previous Board remand was the Veteran's claim for service connection for Posttraumatic Stress Disorder (PTSD). However, since the remand the claim has been reclassified as Unspecified Depressive Disorder and granted by the RO. Therefore, this claim is not currently before the Board.
1. The Veteran has been entitled to a 50 percent rating for migraines, which constitutes the highest rating available for the disability under the VA rating schedule, throughout the entire appeal period.
2. The Veteran's intervertebral disc syndrome of the thoracic and lumbar spine has not been manifested by thoracolumbar forward flexion limited to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes having a total duration of at least four weeks but less than six weeks during a 12 month period were not shown.
3. The Veteran's left leg radiculopathy did not result in moderately severe incomplete paralysis of the sciatic nerve at any point during the period on appeal.
4. The Veteran has mild memory loss and does not have a diagnosis of cerebral arteriosclerosis.
5. The Veteran is not precluded from securing or following a substantially gainful occupation due to a service-connected disability or disabilities.
1. A 50 percent rating is the highest schedular rating available for migraine headaches, and the evidence does not warrant referral for consideration of migraine headaches on an extra-schedular basis. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8100 (2016).
2. The criteria for a rating in excess of 20 percent for intervertebral disc syndrome of the thoracic and lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Codes 5243 (2016).
3. The criteria for a rating in excess of 20 percent for lumbar radiculopathy left side have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8520 (2016).
4. The criteria for rating higher than 10 percent for memory impairment due to undiagnosed illness have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124a, Diagnostic Codes 8046, 9305 (2016).
5. The criteria for a TDIU rating have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.25, 4.26 (2016).
Neither the Veteran nor the representative has raised any issues with the duty to notify. 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 duty to assist argument).
In regard to the duty to assist, the Veteran submitted a statement that he believes that the VA examination done in September 2016 for his back and lower extremity disabilities was inadequate.
VA has a duty to assist a Veteran in the development of a claim. Part of this duty includes getting a VA examination when necessary to adjudicate the claim. Once VA provides an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007).
The Board finds that the September 2016 is adequate to adjudicate the claims. The examiner indicated that the Veteran's complete claims file was reviewed and there was a questionnaire and examination completed. To the extent that the examiner was not able to add more detail to the exam it appears in most part was due to the Veteran's own symptomology of pain. The examiner was not able to complete some of the testing due to the Veteran's pain, but that does not render the opinion inadequate.
As there is enough information to adjudicate the claims, a new examination is not necessary for the Veteran's increased rating claim. To this extent, the Board finds that duty to assist has been satisfied.
Disability ratings are determined by applying the criteria set forth in the 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.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2016).
In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2 (2016); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2016). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2016).
In Hart v. Mansfield, 21 Vet. App. 505, (2007), the United States Court of Appeals for Veterans Claims (Court) recognized entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings."
The Board has reviewed all the evidence in the Veteran's electronic file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim.
The Board had remanded these claims in 2009 because of the lack of clinical evidence assisting VA in determining the proper evaluation for the service-connected disabilities.
Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against an increased rating for any of the Veteran's service-connected disabilities. The reasons for these determinations are explained below.
The Veteran's migraines are rated in accordance with the VA rating schedule under Diagnostic Code 8100. 38 C.F.R. § 4.124a. A 50 percent rating is the highest rating available under Diagnostic Code 8100; this rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id.; see also Pierce v. Principi, 18 Vet. App. 440 (2004).
The Veteran's migraine disability does not warrant a higher rating or extraschedular consideration.
The Veteran's migraines have been rated at a 50 percent disability rating since June 1994. Thus, the Board finds the Veteran has been entitled to the highest rating available for migraines under the VA rating schedule throughout the entire appeal period. See 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. This rating compensates the Veteran for the impairment of earning capacity resulting from his frequent, severe migraines, to include their impact on his occupational functioning, as specifically noted in the rating criteria.
An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1).
The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected migraine headaches with the established criteria found in the rating schedule. The discussion above reflects that the symptoms of the Veteran's headaches as it is are contemplated by the applicable rating criteria, namely the Veteran's frequency of headaches and the effect on his employment. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule. To the extent the Veteran has reported symptoms related to his headaches that result in prostrating attacks and/or prolonged attacks, to include light sensitivity, stabbing pain, fatigue, inability to concentrate those symptoms are contemplated by the 50 percent rating.
In addition, the 50 percent rating takes into account the effects of his headaches on his employability as he has frequently blamed his headaches for the reason he cannot work. In August 2007, the Veteran's private physician suggested that the Veteran may be suffering from an unspecified cerebral disorder based on the symptoms the Veteran prescribed, but also provided that all of the objective neurological findings after testing and physical examination were normal. The physician went on to say that a diagnosis could not be made in the neurological field because the testing gave no indication of neurological abnormalities or change in his disease.
Therefore, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extra-schedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). A review of the evidence during the appeal period demonstrates that the Veteran's headaches have not been as frequent or severe as to suggest that the rating criteria is insufficient. Accordingly, referral for extra-schedular consideration is not indicated.
Because the preponderance of the evidence is against the claim at any time during the pendency of the appeal, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a (2016). The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a (2016).
The General Formula provides that a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine (2016). A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine (2016).
Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (5) (2016).
For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral extension are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note(2) (2016).
Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent rating is assigned where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned where there are incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 20 percent rating is assigned where there are incapacitating episodes having a total duration of at least two week but less than four weeks during the past 12 months. A 10 percent rating is assigned where there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2016). An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note(1) (2016).
In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. 38 C.F.R. § 4.40 (2016). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2016). Factors of joint disability include increased or limited motion, weakness, and fatigability, or painful movement, swelling, deformity or disuse atrophy. 38 C.F.R. § 4.45 (2016).
Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2016). Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011).
The RO has rated the Veteran's low back disability under Diagnostic Code 5243 for intervertebral disc syndrome.
The Board notes that in order for the Veteran's symptomatology to warrant a higher rating of 40 percent under the general spine rating criteria, ankylosis would have to be shown affecting the entire thoracolumbar spine or a forward flexion of only up to 30 degrees. Here, objective medical examination by the September 2016 VA examination report shows no objective evidence of ankylosis at all. Also, while the medical evidence shows pain and limited range of motion due to pain, the pain and other limiting factors are not show to limit the Veteran's thoracolumbar forward flexion to 30 degrees or less as required for a higher rating at any point during the appeals period. During his most recent examination, as the examiner was unable to complete the examination due to pain, the only evidence of the Veteran's forward flexion, at worse during the entire appeals period, is up to 45 degrees which does not meet the necessary criteria for the 40 percent rating. Joint pain alone, including pain throughout the entire range of motion, but without evidence of decreased functioning ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011).
Finally, the Board notes that the Veteran did not have incapacitating episodes of at least four weeks but less than six weeks during a 12 month period which is required for a rating in excess of 20 percent. Instead, the Veteran was found to have to not have any incapacitating episodes in the last 12 month period. Therefore, the Board finds that the Veteran's claim for a rating in excess of 20 percent for an IVDS disability must be denied under this criteria as well.
In considering any other potential diagnostic codes for an increase for the Veteran Diagnostic Code 5003 also provides ratings for arthritis which the Veteran has as part of his back disability. However, a rating under Diagnostic Code 5003 cannot be combined with a rating based on limitation of motion and Diagnostic Code 5003 only provides for 10 percent and 20 percent ratings. Therefore, no higher or separate rating is warranted pursuant to Diagnostic Code 5003 either. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2016).
As the Veteran, does not meet the criteria for the 40 percent increased rating, there is no need to consider the higher ratings as they have additional necessary criteria.
The Veteran is also seeking an increased rating for his radiculopathy of the left leg, currently assigned a 10 percent rating under DC 8520 for paralysis of the sciatic nerve. Under this DC, a 10 percent rating is warranted for mild incomplete paralysis. An increased, 20 percent, rating is warranted for moderate incomplete paralysis. An increased, 40 percent, rating is warranted for moderately severe incomplete paralysis. An increased, 60 percent, rating is warranted for severe incomplete paralysis with marked muscular atrophy. As will be discussed below, the evidence does not establish the Veteran experienced moderate incomplete paralysis of the sciatic nerve at any point during the period on appeal, and his appeal for an increased rating is denied.
At the Veteran's September 2016 VA examination, the examiner at first noted that the Veteran's radiculopathy may have been at a moderately severe severity when just considering a review of the file and the Veteran's subjective statements. However, upon actual physical examination and testing, the examiner determined that the Veteran's radiculopathy was only mild in nature. Objectively, the Veteran's disability does not currently meet the 20 percent rating criteria. Therefore, an increased rating is not warranted.
The Board has considered the Veteran's reports of increased pain due to his left leg disability. However, DC 8520 does not rate on pain alone, but instead contemplates the level of paralysis of the sciatic nerve. The Board finds that the Veteran is not competent to opine as to whether the incomplete paralysis of his left leg radiculopathy can be classified as mild, moderate, or severe. Such an opinion requires medical expertise and knowledge, and the record does not reflect that the Veteran possesses such expertise. Therefore, the Board finds the examination and objective testing more probative to the claim. Based on all the foregoing, the evidence does not establish the Veteran experienced moderately severe incomplete paralysis of the left sciatic nerve at any point during the period on appeal and entitlement to a higher, 40 percent, rating is not warranted.
As the 40 percent rating criteria have not been met, no consideration needs to be given at this time for a 60 or 80 percent rating as they require even more stringent symptomology.
Under 38 C.F.R. § 4.124a , Diagnostic Code 8046, purely neurological disabilities, such as hemiplegia, cranial nerve paralysis, etc., due to cerebral arteriosclerosis will be rated under the diagnostic codes dealing with such specific disabilities, with citation of a hyphenated diagnostic code (e.g., 8046-8207). Purely subjective complaints such as headaches, dizziness, tinnitus, insomnia, and irritability, recognized as symptomatic of a properly diagnosed cerebral arteriosclerosis, will be rated 10 percent and no more under diagnostic code 9305. See 38 C.F.R. § 4.124a, DC 8046. This 10 percent rating will not be combined with any other rating for a disability due to cerebral or generalized arteriosclerosis. Ratings in excess of 10 percent for cerebral arteriosclerosis under diagnostic code 9305 are not assignable in the absence of a diagnosis of multi-infarct dementia with cerebral arteriosclerosis. See id. The ratings under code 8046 apply only when the diagnosis of cerebral arteriosclerosis is substantiated by the entire clinical picture and not solely on findings of retinal arteriosclerosis. See 38 C.F.R. § 4.124a, DC 8046, Note.
The Veteran's undiagnosed memory loss does not meet the necessary criteria for an increased rating.
Included in the Board's August 2009 remand was the request for a medical exam and opinion for the Veteran's reported memory loss to see the current severity. The Veteran received the new examination in September 2016. The examiner stated that the Veteran had no diagnosis of a memory impairing or cognitive disorder. The examiner went on to state that the Veteran had mild memory loss. On examination, except for his self-report, there was no evidence of forgetfulness or memory impairment for items such as names, recent and remote events. As there was no additional diagnosis of dementia or anything else during this examination or otherwise within the claims file, the Veteran cannot receive a higher rating as he is receiving the maximum that it is allowed for an undiagnosed illness of memory impairment under 9305 as determined by 8406.
The Board has also considered other potentially applicable diagnostic codes that provide for the assignment of higher evaluations for the Veteran's disability. After review, however, the Board observes that no other diagnostic code provides for a higher rating based on the evidence of record and that the diagnostic code utilized best addresses his disability picture.
Therefore, the Veteran's claim for an increased rating must be denied.
The Veteran's service-connected disabilities do not prevent him from securing substantially gainful employment.
A total disability rating based upon individual unemployability may be assigned where the schedular rating is less than total, and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2016).
The Veteran already meets the necessary schedular rating criteria for a total disability rating as his service-connected migraines have been rated at a 50 percent disability rating and his other combined service-connected disabilities have brought his total to at least 70 percent since April 2003. The question at hand is whether his service-connected disabilities keep him from securing substantially gainful employment, the Board finds they do not.
The Veteran provided private opinions from his physicians in Germany that state that he is unable to work and has been since 1999. Primarily, the emphasis has been on his service-connected migraines, back and memory loss. As discussed previously, the Veteran has a mild memory loss that does not prevent him from most activities requiring memory. In the 2016 opinion given as part of the service-connected memory loss and unspecified depressive disorder examination, the examiner indicated that while he may have more difficulty concentrating and remembering details, these disabilities do not impair the Veteran from working.
In regard to the Veteran's back and lower extremity disabilities, as part of his 2016 examination, the examiner acknowledged that the Veteran's service-connected radiculopathy and IVDS may impact his ability to do things for extended periods such as walking, lifting or standing or cause an inability to lift, push or pull. However, again the examiner did not state that the Veteran is prevented from working. These factors only affect the type of work that the Veteran can do and establishes he may have to look for work that may better suit his disabilities.
Even in regard to the Veterans migraines, the Board acknowledges the private physicians' statements in regard to the Veteran's inability to work, however, the opinions appear to be based on subjective statements from the Veteran. The Veteran's statements and actions throughout the appeal have not been consistent with the clinical evidence in terms of severity. Throughout the file the clinical findings have shown significantly less injury and damage to the Veteran than the Veteran has personally stated. Therefore, the Board finds that the physicians' opinions that rely so heavily on the Veteran's statements to carry less probative value and weight than others containing more objective findings.
Given the above, the preponderance of the evidence is against finding that the Veteran's service-connected disabilities completely preclude his participation in any form of substantially gainful employment at any time during the appeal period. Thus, a TDIU rating is not warranted and the claim is denied for the entire period on appeal. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra.
Entitlement to a disability rating in excess of 50 percent for migraine headaches is denied.
Entitlement to a disability rating higher than 20 percent for intervertebral disc syndrome of the thoracic and lumbar spine (IVDS) is denied.
Entitlement to a disability rating higher than 20 percent for left lower extremity neurological impairment as a result of disc prolapse at L5-S1 is denied.
Entitlement to a disability rating higher than 10 percent for memory impairment due to undiagnosed illness is denied.
Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is denied.

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