Citation Nr: 1705182 Decision Date: 02/21/17 Archive Date: 02/28/17 DOCKET NO. 04-24 569 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 30 percent for myasthenia gravis (MG), to include cramps in the feet and hands, left eyelid ptosis, diplopia, and headaches. 2. Entitlement to an initial disability evaluation in excess of 10 percent for scarring associated with MG. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD J. T. Sprague, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In January 2007, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge (VLJ) sitting in Washington, DC. A transcript of the hearing has been associated with the Veteran's claims folder. In September 2013, pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F.3d 1312 (Fed. Cir. 2013), the Board sent the Veteran a letter notifying him of an opportunity to receive a new decision from the Board that would correct any potential due process error relating to the duties of the VLJ that conducted the January 2007 hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). In October 2013, the Veteran responded that he wished to have the prior decision vacated and a new one issued. However, he declined a new hearing. In April 2014, the Board vacated that portion of its May 2012 decision that denied entitlement to a disability rating in excess of 30 percent for the Veteran's MG. In May 2014, the Board remanded the Veteran's claim to the Agency of Original Jurisdiction (AOJ), to include obtaining additional treatment records and another VA examination. In August 2014, the RO implemented the Board's May 2012 award of a separate 10 percent evaluation for a painful thymectomy scar. The assigned rating was effective from June 1, 2003. In November 2012, the Board again denied an initial disability evaluation in excess of 30 percent for MG. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In October 2015, the Court vacated the November 2014 Board decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Remand (Joint Motion). In the Joint Motion, the parties determined that remand was warranted to address whether the painful thymectomy scar warranted an increase in evaluation and, as noted in detail below, for the Board to appropriately consider manifestations of generalized weakness associated in all four limbs as a consequence of MG (as opposed to solely the feet, which were the only extremities discussed in the vacated 2014 decision). In December 2015, the Board remanded the claims so that additional medical evidence could be obtained with respect to those manifestation noted by the Court, and the claims are now ripe for appellate review. FINDINGS OF FACT 1. The Veteran's myasthenia gravis (MG) is manifested by mild bilateral eye ptosis that does not affect vision; mild bilateral peripheral retinal changes without loss or contraction of visual fields, decrease in visual acuity or disfigurement; weakness in the limbs approximately once every few weeks that is not productive of limitations to gait or strength (and which respond well to medication); weekly muscle cramps of the feet, calves and thighs, quickly relieved by stretching, without any loss of joint range of motion; normal speech, gait, strength, deep tendon reflexes; and tension headaches about 1-2 times per week that are not prostrating. 2. The Veteran experiences three small scars associated with thymectomy residuals which, when considered together, are not painful and/or unstable; some pain has historically been associated with individual scarring, but this is not consistent and has not applied to all (three) residuals scars. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 30 percent for myasthenia gravis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.79, 4.84a (2008), 4.88b, 4.118, 4.124a, Diagnostic Codes 6019, 6090 (2008), 6354, 7800, 8025, 8100 (2016). 2. The criteria for an initial disability evaluation in excess of 10 percent for thymectomy scarring associated with MG have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.79, 4.118, Diagnostic Codes 7803, 7804 (2008), 7804 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). Separate Diagnostic Codes ("DC") identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2016). 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 Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2016). 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). 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. 38 C.F.R. § 4.7 (2016). In determining the adequacy of assigned disability ratings, consideration is also given to factors affecting functional loss. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use, including that experienced during flare ups. 38 C.F.R. § 4.40. Consideration is also given to weakened movement, excess fatigability, and incoordination, as well as the effects of the disability on the Veteran's ordinary activity. 38 C.F.R. § 4.10, 4.45. The Veteran's myasthenia gravis is currently evaluated as 30 percent disabling under DC 8025. 38 C.F.R. § 4.124a. A diagnosis of myasthenia gravis with ascertainable residuals warrants the assignment of a minimal rating of 30 percent. Under the provisions of 38 C.F.R. § 4.124a, consideration should also be afforded to psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors and visceral manifestations. A note accompanying DC 8025 specifies that there be ascertainable residuals of the disorder. Determinations as to the presence of residuals not capable of objective verification (i.e., headaches, dizziness, fatigability), must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to another disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses. Id. at Note 1. In other words, a higher rating may be assigned based upon the combined evaluations of the residual disorders. Thus, the question here is whether there is sufficient evidence of identifiable residual disorders resulting from the Veteran's service-connected myasthenia gravis, which when combined, may exceed the 30 percent rating currently assigned. The preponderance of the evidence indicates that there are no residuals of the Veteran's disorder that may be further compensated by the applicable rating code. The Veteran's myasthenia gravis is currently manifested by mild bilateral eye ptosis that does not affect vision; mild bilateral peripheral retinal changes without loss or contraction of visual fields, decrease in visual acuity or disfigurement; weakness in the limbs approximately once every few weeks (responsive to medication); weekly muscle cramps of the feet, calves and thighs, quickly relieved by stretching, without any loss of joint range of motion; tension headaches about 1-2 times per week that are not prostrating; and normal speech, gait, strength, deep tendon reflexes. The Board, in its 2014 decision, properly addressed all symptomatology associated with the Veteran's myasthenia gravis save for noted residual weakness and fatigability. Indeed, in the Joint Motion for Remand between the Secretary of Veterans Affairs and counsel for the Veteran, it was noted that the Board erred when it limited its consideration of weakness to the bilateral feet. The record had indicated generalized weakness in all extremities, and the Board was directed to make considerations of those findings so as to be sure to adequately provide reasons and bases for the decision. Also, the residual scar, evaluated at 10 percent disabling, was also considered to be in appellate status, and the Board was to discuss it following the Court's order. In that respect, the Board will incorporate its findings from the 2014 decision with respect to all symptoms save for weakness in the four extremities and the severity of the residual scar, which it will add to the previous, unchallenged discussion of facts. Bilateral Eye Ptosis, Mild Peripheral Retinal Changes and Scarring. Ptosis is evaluated under DC 6019. Rating criteria for disabilities of the eye were changed, effective December 10, 2008. See 73 Fed. Reg. 66,543 (Nov. 10, 2008). Where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. However, only the former criteria can be applied for the period prior to the effective date of the new criteria, but both the old and new criteria can be applied as of that date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C.A. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000 (Apr. 10, 2000). The previous version of DC 6019 (prior to December 10, 2008), provided that unilateral or bilateral ptosis with the pupil wholly obscured should be rated equivalent to 5/200. Unilateral or bilateral ptosis with the pupil one-half or more obscured should be rated equivalent to 20/100. Unilateral or bilateral ptosis with less interference with vision should be rated as disfigurement. The impairment of central visual acuity is evaluated from 0 to 100 percent under DCs 6061 through 6079. Also, DC 6080 provides ratings for impairment of field vision from 10 to 100 percent. 38 C.F.R. § 4.84a (2008). The post-December 10, 2008 Diagnostic Code 6019 provides that unilateral or bilateral ptosis is evaluated on visual impairment or, in the absence of visual impairment, on disfigurement (scarring), per DC 7800. 38 C.F.R. § 4.79 (2016). Left eyelid ptosis was noted at the Veteran's May 2003 VA neurological examination and June 2003 VA eye examination. However, his vision without correction was 20/20 for distance and 20/25 for near, but was correctable to 20/20. Left eyelid ptosis was also diagnosed at his October 2009 VA neurological examination, where the examiner noted that it was mild. According to the November 2010 VA examination report, Veteran only had a "tiny degree" of left eyelid ptosis, which did not involve the visual axis. During the June 2014 examination, the Veteran was found to have mild bilateral ptosis without any decrease in visual acuity or other visual impairment. His vision without correction was 20/20 for distance, and was correctable to 20/20 for near. Because the Veteran's bilateral eyelid ptosis does not impact his vision, DC 7800 will be considered. Prior to the October 2008 amendments to the rating criteria for scars, DC 7800 for the evaluation of disfigurement of the head, face or neck provided that a 10 percent disability rating is assigned when there is one characteristic of disfigurement. See 38 C.F.R. § 4.118, DC 7800 (2008). Additionally, superficial scars, whether stable and painful or unstable in nature, were rated as 10 percent disabling. See 38 C.F.R. § 4.118, DC 7803, 7804 (2008). Under Note (1), the eight characteristics of disfigurement are: a scar 5 or more inches (13 or more cm.) in length; a scar at least 1/4 inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; a scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39-sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 square inches (39-sq. cm.); and skin indurated and inflexible in an area exceeding 6 square inches (39- sq. cm.). Id. Pursuant to Note (2), tissue loss of the auricle is to be rated under DC 6207 (loss of auricle) and anatomical loss of the eye is to be rated under DC 6063 as appropriate. Pursuant to Note (3), the adjudicator is to take into consideration unretouched color photographs when evaluating under these criteria. Id. Following the October 2008 regulation change, the diagnostic criteria under DC 7800 essentially remained the same. However, the description was amended to clarify that ratings applied to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800 (2016). The eight characteristics of disfigurement remained the same. However, additional explanatory notations were added, which state that disabling effects other than disfigurement that are associated with individuals scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, should be separately evaluated under the appropriate DCs. Also, the characteristic(s) of disfigurement may be caused by one scar or multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118, DC 7800, Notes 4 & 5 (2016). In addition, one or two scars that are unstable or painful are deemed 10 percent disabling, three or four scars that are unstable or painful are 20 percent disabling, and five or more scars that are painful or disabling are 30 percent disabling. 38 C.F.R. § 4.118, DC 7804 (2016). Here, the Veterans bilateral eyelid ptosis does not cause any characteristics of disfigurement. He does not have a scar, hypo-or hyperpigmented skin, missing underlying soft tissue, or indurated and inflexible skin in an area exceeding 6 inches. A June 2016 dermatology examination noted the residual scars associated with the Veteran's service-connected disability, and three scars were found at 3 cm, 2.5cm, and 2.5cm. The three scars were not, considered together, found to be painful or unstable. As such, the criteria for a separate, 10 percent evaluation under DC 7800 are not met under the previous or amended criteria, and as the three scars are not all either painful or unstable, a rating in excess of 10 percent is not warranted for the residuals scars under any legal criteria effective for the period under review. Diplopia During the October 2009 examination, the Veteran previously reported experiencing diplopia (double vision) once every two months; he said that the symptoms were relieved by taking prednisone. During the November 2010 examination, he reported exacerbations of diplopia every two months, but the examiner was unable to elicit the condition on prolonged gaze. During the June 2014 eye examination, however, the Veteran denied diplopia. Prior to December 10, 2008, DC 6090 pertained to rating of diplopia. 38 C.F.R. § 4.84a (2008). Under DC 6090, ratings were based on the degree of diplopia and the equivalent visual acuity. The ratings were applicable to only one eye. A rating could not be assigned for both diplopia and decreased visual acuity or field of vision in the same eye. 38 C.F.R. § 4.84a, Diagnostic Code 6090, Note 2. Since December 18, 2008, diplopia has been evaluated using DC 6090, codified at 38 C.F.R. § 4.79 (2016). Diplopia is rated according to the equivalent visual acuity. If it is occasional or correctable with spectacles, it is noncompensable. Id. Accordingly, as the Veteran's diplopia has been a temporary exacerbation and does not result in a permanent disability, it does not warrant a disability evaluation. Weakness in the Limbs Although there is no diagnostic code available solely to evaluate weakness of the limbs, under 38 C.F.R. § 4.72, DC 5277, weak foot, bilateral, is defined as a symptomatic condition secondary to many constitutional conditions, characterized by atrophy of the musculature, disturbed circulation and weakness. The underlying condition is to be rated at 10 percent at a minimum. Id. Here, however, there was no indication during any of the VA examinations that the Veteran had weakness of either foot characterized by muscle atrophy or disturbed circulation. Accordingly, the criteria for a 10 percent evaluation under DC 5277 have not been met at any time during the appeals period. Pursuant to the recent remand done in concert with the Court's order to vacate the 2014 decision, the Board remanded the claim for a neurology examination to ascertain residual disability in the form of weakness in any of the Veteran's limbs. The associated report of examination, dated in June 2016, noted that the Veteran had never been hospitalized for the condition of myasthenias gravis, either during stable or exacerbating periods. There was "episodic general weakness" from time to time which is fully responsive to steroid treatment. Strength and gait were normal for all four limbs, and weakness was expressly found to be "none" for the left and right upper and lower extremities after objective testing. No assistive devices for ambulation were needed. Indeed, even considering that the Veteran has some general periods of weakness associated with all four limbs, it is clear that such manifestations do not prevent ambulation, lifting, or any other type of movement to a significant degree (and when there is some impairment, the symptoms are responsive to prescribed medication. Further, because the limb weakness is a temporary exacerbation and does not result in a permanent disability, the condition, in all extremities and on a general systemic basis, does not warrant additional disability evaluation. See Voerth v. West, 13 Vet. App. 117 (1999). Muscle Cramps During his May 2003 VA general medical examination, the Veteran reported daily hand and foot cramps lasting for a few seconds and then spontaneously resolving. During the October 2009 VA neurological examination, he reported having cramps in his feet and legs at least once a week, which the examiner described as moderate. The November 2010 examination reports shows that the Veteran reported muscle cramps every other day in his calves, triceps, and sometimes deltoids. He stated that he rested a little and they stopped. The examiner determined that the cramps did not cause an enduring focal loss of muscle strength. The examiner also concluded that the Veteran did not have joint symptoms or loss of range of motion due to myasthenia gravis. During the June 2014 neurological examination, the Veteran reported painful cramps in the muscles of the feet, calves and thighs, which he said had lessened to about once per week, but were quickly relieved by stretching. The examiner noted that these muscle cramps resulted in no restricted range of motion of the hands, feet or legs. Although the Veteran experiences muscle cramps approximately once per week, this condition does not warrant a disability evaluation, as it is a temporary exacerbation and does not result in a permanent disability. See Voerth v. West, supra. Headaches The Veteran has reported headaches as a residual of his myasthenia gravis. Headaches are evaluated under 38 C.F.R. § 4.124a, DC 8100, migraines. Under DC 8100, a 10 percent evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A noncompensable evaluation is warranted for less frequent attacks. The rating criteria do not define "prostrating." By way of reference, according to DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 1367 (28th Ed. 1994), "prostrating" is defined as "extreme exhaustion or powerlessness." In a February 2004 private medical record, the Veteran reported having headaches every couple of days, but stated that they were usually not very severe and they resolved quickly after he took over-the-counter medication. The Veteran also reported headaches during the October 2009 VA examination. The examiner found that he had mild tension headaches as a result of myasthenia gravis. During his November 2010 VA examination, the Veteran reported having headaches every other week that lasted for one day. He denied nausea, vomiting, sensitivity to light or noise, or focal phenomena. The examiner found that the Veteran's headaches were not prostrating and that ordinary activity was possible during an attack. During the June 2014 headache examination, the Veteran reported that he experienced dull, aching, bifrontal headaches about 1-2 times per week, that could last for a few hours, and were relieved with over-the-counter medications, including Tylenol. The examiner diagnosed the condition as tension headaches and noted that they were not prostrating. As the evidence shows that the Veteran does not experience prostrating attacks, his headaches do not meet the criteria for a compensable evaluation under DC 8100. 38 C.F.R. § 4.124a. See Voerth v. West, supra. In addition to the medical evidence, the Board has also considered the statements of the Veteran regarding the severity of his myasthenia gravis residuals. The Veteran is competent to report factual matters of which he or she has first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while he is competent to report his symptoms, the Board finds there is no evidence that he has medical knowledge or training that would permit him either to determine the severity of a complex medical condition such as myasthenia gravis; identify which of his symptoms would be attributable to the disorder or analyze the severity of such symptoms under the appropriate diagnostic codes. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). His statements in that regard are not competent. Conclusion In conclusion, the Veteran's residuals from myasthenia gravis do not meet the criteria for a disability evaluation in excess of 30 percent under their respective diagnostic codes, or do not constitute permanent disabilities. With respect to the separately identified 10 percent evaluation for scarring residuals, the Board also concludes that a higher schedular rating is not warranted. Rather, the Board finds that the overall disability picture for his myasthenia gravis and scarring do not more closely approximate a higher rating. 38 C.F.R. § 4.7. As the preponderance of the evidence is against the claims, the "benefit-of-the-doubt" rule is not applicable. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Moreover, as the Veteran's symptoms from myasthenia gravis have not met the criteria for a higher rating at any time since the effective date of his award, staged ratings are not applicable. Fenderson, 12 Vet. App. at 125-26. The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis during any portion of the appeals period. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that 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 would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321 (b)(1) (2014). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. There are no symptoms that are unusual or different from those contemplated by the schedular criteria. The Veteran does not demonstrate exceptional or unusual disability; he merely disagrees with the assigned evaluation. Accordingly, given the lack of evidence showing unusual disability not contemplated by the rating schedule, the Board concludes that referral for an extraschedular evaluation under 38 C.F.R. § 3.321 (b)(1) is not warranted. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, the Board has considered whether entitlement to a total disability rating based on individual unemployability (TDIU) is warranted. When entitlement to TDIU is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). There is competent evidence to show that the Veteran has never been unemployable as a result of his service-connected disabilities. During the June 2014 examination, he reported that he was employed fulltime as an aircraft mechanic, and this was confirmed by the 2016 examinations which showed continual employment. He said that he had lost approximately one week from his job due to the myasthenia gravis in 2014, and while the 2016 findings showed approximately six weeks of missing time per year, it was noted that "symptoms most of the time are under good control." "Worsening weakness" could happen, but the Veteran was still gainfully employed and his symptoms were noted to respond to treatment. As regards overall impairment, the 2016 VA neurology assessment noted that weakness, which "waxes and wanes," can cause restriction of daily activities and periods of incapacitation for "at least two," but "less than four" total weeks per year. This does not suggest a TDIU, and when considered with all factors, fully supports assignment of a 30 percent evaluation for the myasthenia and separate 10 percent evaluation for residuals of surgical scarring. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). Based on all of the above, the claims for an increase will be denied. ORDER Entitlement to an initial disability evaluation in excess of 30 percent for myasthenia gravis (MG), to include cramps in the feet and hands, left eyelid ptosis, diplopia, and headaches is denied. Entitlement to an initial disability evaluation in excess of 10 percent for scarring associated with MG is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs