Citation Nr: 23035308 Decision Date: 06/22/23 Archive Date: 06/22/23 DOCKET NO. 19-34 822 DATE: June 22, 2023 ORDER From September 29, 2017, entitlement to an initial rating of 50 percent for migraines is granted, subject to the laws that govern the payment of monetary benefits. From September 29, 2017, entitlement to an initial rating of 30 percent for polycystic ovarian syndrome is granted, subject to the laws that govern the payment of monetary benefits. REMANDED Entitlement to a compensable rating for hirsutism is remanded. FINDINGS OF FACTS 1. The evidence persuasively demonstrates that the Veteran's disability picture of the Veteran's migraine headaches results in prostrating and prolonged attacks productive of severe economic inadaptability for entire period on appeal. 2. The evidence shows that the Veteran's polycystic ovarian syndrome is manifested by symptoms not controlled by continuous treatment for the entire period on appeal. CONCLUSIONS OF LAW 1. The criteria for an initial 50 percent rating for the Veteran's headaches have been met. 38 U.S.C. §§ 1101, 1110, 1113; 38 C.F.R. §§ 4.124a, Diagnostic Code 8100; 4.3, 4.7. 2. The criteria for an initial 30 percent rating for polycystic ovarian syndrome have been met. 38 U.S.C. §§ 1101, 1110, 1113; 38 C.F.R. §§ 4.116, Diagnostic Code 7615. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2013 to September 2017. This matter is on appeal from an October 2017 rating decision and was previously remanded by the Board in April 2020. The Veteran did not initially disagree with the October 2017 rating decision and instead filed a claim for an increased rating in February 2018. However, as new and material evidence was received within a year of the October 2017 rating decision, it did not become final. Therefore, the Board finds the October 2017 rating decision is on appeal. Increased Rating Disability evaluations are determined by the application of facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) in 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred in or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. Migraines Migraine headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100, for migraine. Under DC 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App.?245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristics prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. Procedurally, the Veteran was initially granted service connection for migraine headaches by an October 2017 rating decision and was assigned a noncompensable rating. On February 14, 2018, VA received the Veteran's Intent to File a Claim for an increased rating, which was granted by the AOJ, and was assigned a 30 percent rating by an August 2020 rating decision. The Board concludes that the Veteran's migraines have occurred with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, corresponding to the criteria for a 50 percent rating under DC 8100. Based on the Veteran's April 2018 Disability Benefits Questionnaire, she complained of pain in the right frontal lobe with visual changes, with light and noise sensitivity. She also had nausea and vomiting that last approximately two days, occurring twice a week. She noticed worsening symptoms given the increased severity and frequency, even causing her to miss work a couple of days a month. Upon evaluation, the examiner noted that the Veteran's migraine result in pulsating/throbbing head pain, and pain localized to one side of the head. Her symptoms also include nausea, sensitivity to light and sound, with changes in vision, lasting approximately 1 to 2 days. Her symptoms did not result in characteristic prostrating attacks of migraine. It did not cause prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. She did not exhibit any other pertinent physical findings or complications associated with her migraines. In October 2019, the Veteran reported migraines that occur daily that last anywhere from hours to a few days. The pain is severe and debilitating with symptoms such as constipation, mood changes, food cravings, neck stiffness, increased thirst and urination. She also experiences bright spots, flashes of light, vision loss, weakness, difficulty speaking, and pins and needle sensations in her arms and legs. After her migraine episodes, she often feels drained, tired, and confused. Her migraines affect her ability to work or deal with people. She has taken various pain medications to alleviate her symptoms but to no avail. See October 2019 VA Form 9. When the matter came to the Board in April 2020, it was remanded to afford the Veteran a new VA examination to assess the severity of her migraines. Based on the April 2020 VA examination report, the Veteran indicated that her migraines occur approximately 3 to 5 times per week, resulting in excruciating pain and light sensitivity, requiring her to lie down in a dark room. While she has been prescribed several medications, some has made her migraines worse. The Veteran's symptoms include constant head pain, pulsating and throbbing sensations, pain on both sides of the head, which worsens with physical activity. She also has nausea, sensitivity to light, and changes in vision, which lasts from 1 to 7 days. Moreover, the Veteran's migraines result in very prostrating and prolonged attacks. The Board finds that the medical evidence demonstrates that the Veteran's migraine headaches most proximate a rating of 50 percent for the entire period on appeal. While the Veteran's April 2018 evaluation noted that the Veteran's migraines did not result in prostrating attacks, the Board notes that she reported severe migraine episodes that last for days at a time, resulting in her missing work every month. Additionally, the Veteran has credibly and competently reported debilitating pain with severe symptoms such as sensitivity to light and sound, pain, vision loss, and weakness. More recently, the Veteran's lay complaints were then confirmed by an examination in April 2020, which clearly shows that her migraines result in prostrating attacks. Therefore, affording the benefit of the doubt to the Veteran, the Board finds that the Veteran's migraines more proximate the rating of 50 percent (the maximum schedular rating) for the entire period on appeal. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27?Vet. App.?484, 495 (2016); Doucette v. Shulkin, 38?Vet. App.?366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Polycystic ovarian syndrome The Veteran's polycystic ovarian syndrome is rated under 38 C.F.R. § 4.116, Diagnostic Code 7615. Procedurally, the Veteran was granted service connection for her polycystic ovarian syndrome and was assigned a noncompensable rating by an October 2017 rating decision. The Veteran filed her increased rating claim in February 2018. In August 2020, the AOJ assigned an increased rating of 10 percent, effective February 14, 2018, the date on which her Intent to File was received by VA. Under the General Rating Formula for Diseases, Injuries, or Adhesions of Female Reproductive Organs (diagnostic codes 7610 through 7615), symptoms that do not require continuous treatment warrant a noncompensable disability rating; symptoms that require continuous treatment warrant a 10 percent disability rating; and symptoms not controlled by continuous treatment warrant a 30 percent disability rating. See 38 C.F.R. § 4.116, Diagnostic Code 7615. Note: For the purposes of VA disability evaluation, a disease, injury, or adhesion of the ovaries resulting in ovarian dysfunction affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under Diagnostic Code 7615. The Veteran indicated that her polycystic ovarian syndrome has resulted in abnormal uterine bleeding with infrequent, irregular, and prolonged menstrual cycles. Her ovarian condition is not controlled by the medications taken for it and causes cramping and pain. She was told by her physician that her ovary is enlarged. See November 2019 VA Form 9. The Veteran submitted photographs that showed hair growth on her chin and jawline. See November 2019 Photographs. At her April 2018 VA evaluation, the Veteran reported severe and intermittent pain, pelvic pressure, irregular menstruation, dysmenorrhea associated with ovarian dysfunction, and frequent or continuous menstrual disturbances. The Veteran has been prescribed Metformin daily (since 2016). There was no evidence of clinical abnormalities pertaining to the vulva, clitoris, vagina, cervix, or fallopian tubes. The Veteran has not had a hysterectomy or oophorectomy. She did not exhibit symptoms of menopause or atrophy of either ovary. She denied any urinary incontinence, rectovaginal fistula, urethrovaginal fistula, or endometriosis. There was no evidence of any pelvic organ prolapse. She did not exhibit any other pertinent physical findings, complications, or conditions related to her polycystic ovarian syndrome. Based on a June 2020 VA Disability Benefits Questionnaire, the Veteran stated her condition resulted in moderate pain with pelvic pressure, irregular menstruation, dysmenorrhea, frequent or continuous menstrual disturbances, weight gain, mood swings, and intermittent pain. She has been treated with medications, which include Metformin, Progestin, and Spironolactone. Her ovarian condition now results in urinary incontinence with leakage, requiring absorbent material that is changed less than 2 times per day. It has not resulted in rectovaginal fistula, urethrovaginal fistula, endometriosis, or pelvic organ prolapse. There is no evidence of tumors or neoplasm. The Board notes that in a September 2020 rating decision, the Veteran was granted service connection for urinary incontinence secondary to the Veteran's ovarian disorder. The Veteran has not disagree with the initial rating or the effective date of service connection for urinary incontinence; therefore, these issues are not on appeal before the Board. Overall, the Board finds that a rating of 30 percent is warranted for the Veteran's polycystic ovarian syndrome for the entire period on appeal. The Veteran's medical record shows that she has been prescribed medication for her ovarian condition since 2016. First, she was prescribed Metformin since 2016. However, she continued to experience pain with irregular menstrual cycles. In 2020, the Veteran's medications also included Progestin and Spironolactone. Despite the increased medication, she complained of irregular menses, pelvic pressure and pain with dysmenorrhea, weight gain, and mood swings. As the Veteran has symptoms not controlled by medication, the Board finds that a rating of 30 percent is warranted throughout the period on appeal. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27?Vet. App.?484, 495 (2016); Doucette v. Shulkin, 38?Vet. App.?366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Entitlement to an initial compensable rating for hirsutism is remanded. As noted above, the Veteran's polycystic ovarian syndrome has resulted in additional conditions, to include additional hair growth. She was granted service connection for hirsutism and assigned a noncompensable rating under diagnostic code 7899-7831. The Veteran sought an increased rating. When the matter came to the Board in April 2020, the Board noted that the Veteran's hirsutism was rated under Diagnostic Code 7831, which was not appropriate as the code pertained to alopecia areata (loss of body hair). In contrast, hirsutism is a condition that results in excessive hair; specifically unwanted male-like pattern hair growth on the face, chest, and neck. Therefore, the Board found that the most appropriate diagnostic code is 7806, which considers both dermatitis and eczema (manifested by the abnormal growth of a scaly rash on the skin) and the use of systemic therapy. Pursuant to the Board's remand directives, the Veteran attended a VA Skin Diseases examination in June 2020. The examiner diagnosed hirsutism and acne. The examiner noted an irregular hair pattern on the Veteran's face, neck and chin, determining the hirsutism affects less than 5 percent of her total body area and less than 5 percent of the exposed area. The Veteran reported that she developed secondary acne on her face/chin regions from the use of spironolactone for her polycystic ovary syndrome. Despite the Veteran's report about what caused her acne and treatment records which confirm the use of spironolactone, the examiner did not clearly state whether the Veteran's acne was caused or aggravated by her polycystic ovary syndrome or hirsutism. The examiner also indicated the Veteran's hirsutism did not cause scarring or disfigurement. The Board notes that Diagnostic Code 7806 states that the service-connected disability is to be evaluated under the General Rating Formula for the Skin. In addition to specifying criteria for various ratings, the General Rating Formula for the Skin also states that a disability may be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the predominant disability. The Board observes that photographs received in October 2019 may suggest scarring from the Veteran's hirsutism. On remand, the AOJ should obtain an opinion as to whether the Veteran's acne is caused or aggravated by her polycystic ovary syndrome or hirsutism. In addition, the AOJ should obtain a VA Scars/Disfigurement examination to more clearly answer whether the Veteran's hirsutism causes any scarring to her face, neck, or chin. The matters are REMANDED for the following action: 1. Forward the record and a copy of this Remand to the examiner who provided the June 2020 VA Skin Diseases examination for the Veteran's hirsutism, or, if that examiner is unavailable, to another clinician, for completion of an addendum medical opinion. The clinician should address: (a.) Whether the Veteran's acne is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) caused or aggravated (worsened) by her service-connected polycystic ovary syndrome? (b.) Whether the Veteran's acne is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) caused or aggravated (worsened) by her service-connected hirsutism? A complete rationale should be provided. 2. Obtain a VA examination in which the examiner clearly details any scarring or disfigurement caused by the Veteran's hirsutism, including the approximate area that is affected. See photographs received in October 2019. Please provide a completed Scars/Disfigurement Disability Benefits Questionnaire. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Yeh, Nicole 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.