Billy D. McCarroll v. Robert A. McDonald

UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO. 14-2345
BILLY D. MCCARROLL, APPELLANT,
V.
ROBERT A. MCDONALD,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
On Appeal from the Board of Veterans' Appeals
(Decided November 7, 2016)
Matthew J. Ilacqua, of Providence, Rhode Island, was on the brief for the appellant.
Leigh A. Bradley, General Counsel; Mary Ann Flynn, Assistant General Counsel; Thomas
E. Sullivan, Deputy Assistant General Counsel; and Rudrendu Sinhamahapatra, all of Washington,
D.C., were on the brief for the appellee.
Before DAVIS, Chief Judge; KASOLD, LANCE, SCHOELEN, PIETSCH, BARTLEY, and
GREENBERG, Judges; and HAGEL, Senior Judge.1
LANCE, Judge, filed the opinion of the Court. KASOLD, Judge, filed an opinion
concurring in part in which SCHOELEN, Judge, joined. HAGEL, Senior Judge, filed a dissenting
opinion in which GREENBERG, Judge, joined.
LANCE, Judge: The appellant, veteran Billy D. McCarroll, appeals through counsel a
June 4, 2014, decision of the Board of Veterans' Appeals (Board) that, in part, denied entitlement
to an initial compensable disability rating for hypertension.2 Record (R.) at 1-14. This case was
submitted to a panel for decision on January 15, 2016, and a panel of the Court heard oral argument
1
Judge Davis became Chief Judge on October 10, 2016. Judge Hagel is a recall-eligible judge who has been
recalled to further service by the Chief Judge. 38 U.S.C. § 7257(b)(1); U.S. Vet. App. Misc. No. 09-16 (Oct. 13, 2016).
2
The Court lacks jurisdiction over the appellant's claim for entitlement to service connection for liver disease,
which the Board remanded, and it will not be addressed further. See 38 U.S.C. §§ 7252(a), 7266(a); Howard v. Gober,
220 F.3d 1341, 1344 (Fed. Cir. 2000).
on April 12, 2016.3 On July 1, 2016, this case was submitted to the full Court for review pursuant
to part VII of the Court's Internal Operating Procedures.
For the reasons that follow, the Court will affirm that part of the Board's June 2014 decision
now on appeal. In addition, the Board dismissed the appellant's claims for entitlement to service
connection for a neck disorder, bilateral hearing loss, tinnitus, and sinusitis, as well as his claims for
entitlement to increased initial disability ratings for left shoulder strain, right carpal tunnel
syndrome, and choroidal nevus of the right eye. R. at 9. As the appellant presents no argument as
to those determinations, the Court will deem those matters abandoned and will accordingly dismiss
the appeal as to those issues. See Pederson v. McDonald, 27 Vet. App. 276, 283 (2015) (en banc).
I. BACKGROUND
The appellant served in the U.S. Army from December 1983 to September 1992 and from
January 1994 to August 2009. R. at 724-25. A September 14, 2008, service treatment record (STR)
reflects blood pressure readings of 132/95 and 128/95. R. at 946. A March 2, 2009, STR noted a
history of borderline hypertension. R. at 928. The examiner recorded blood pressure readings of
112/79, 144/92, and 142/88, and recommended a five-day blood pressure check. R. at 928. Records
dated between March 3, 2009, and March 5, 2009, note blood pressure readings of 128/88, 138/80,
156/100, 148/96, 120/92, and 126/90. R. at 761, 919. On March 5, 2009, the appellant filed a claim
for entitlement to service connection for hypertension. R. at 786-96.
On April 1, 2009, a private cardiologist prescribed the appellant Lisinopril,4 10 mg. R. at
755-57. The following day, the appellant underwent a VA examination; the examiner observed that
"[the appellant] has had occasional blood pressure elevations at routine physical examinations." R.
at 739. The examiner noted that the appellant had just been prescribed Lisinopril by his cardiologist
and he diagnosed the appellant with essential hypertension. R. at 739, 741. That same day, the
appellant's blood pressure was measured as 141/94 in the right arm while sitting, 117/78 in the left
arm while sitting, and 116/79 while standing. R. at 470.
3
Matthew J. Ilacqua, of Providence, Rhode Island, argued for the appellant. Nicolas R. Esterman, of
Washington, D.C., argued for the Secretary.
4
Lisinopril is a medication prescribed for hypertension. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1065
(32d ed. 2012).
2
In an October 2009 rating decision, the Salt Lake City, Utah, VA regional office (RO)
granted service connection for hypertension and assigned a noncompensable rating. R. at 674-79,
683-705. The appellant filed a Notice of Disagreement in October 2009, R. at 673, and perfected
his appeal in October 2010, R. a 613-15.
A private medical record from May 2010 reflects a blood pressure reading of 148/95. R. at
533. In November 2010, the appellant underwent another VA examination. R. at 584-89. The
examiner noted that the appellant's blood pressure "demonstrates good control with normal readings"
and that the appellant's Lisinopril dosage had increased to 20 mg. R. at 585. The appellant's blood
pressure was recorded as 133/86 on March 31, 2011, R. at 458, and as 127/84 on July 9, 2012, R.
at 343. At a November 2012 Board hearing, the appellant testified that his diastolic blood pressure
readings were over 100 "two or three times" before he began taking blood pressure medication. R.
at 245-46. He also testified that he believed his blood pressure would be higher if he were not taking
his medication. R. at 244-45.
In June 2014, the Board denied entitlement to an initial compensable rating for hypertension
under 38 C.F.R. § 4.104, diagnostic code (DC) 7101 (hypertensive vascular disease). R. at 1-14.
The Board found that "[the appellant's] hypertension has not manifested with diastolic pressure
predominantly 100 or more, with or without medication; or, systolic pressure predominantly 160 or
more throughout the initial rating period." R. at 4. The Board acknowledged the appellant's
argument that he would meet the criteria for a 10% disability rating if he were not using medication.
R. at 8. The Board determined, however, that this assertion was "inaccurate," as "prior to being
placed on medication, the [appellant] was diagnosed with occasional slightly elevated blood pressure
readings" and "the preponderance of the evidence shows he does not have a history of diastolic
pressure predominantly 100 or more." R. at 8-9. This appeal followed.
II. THE PARTIES' ARGUMENTS
The appellant argues that the Board erred when it denied entitlement to a compensable rating
for hypertension on a schedular basis and when it determined that he was not entitled to referral for
consideration of whether an extraschedular rating was warranted. Appellant's Brief (Br.) at 4-19.
With respect to his schedular evaluation, the appellant raises three contentions. First, he asserts that
the Board "failed to properly address the effects of [his] need for continuous medications for control
3
of his hypertension" and misinterpreted the rating criteria for hypertension under DC 7101. Id. at
5, 4-16. Specifically, he argues that the Board violated the Court's holding in Jones v. Shinseki,
26 Vet. App. 56, 63 (2012), by failing to discount the ameliorative effects of his blood pressure
medication. Id. at 10-11. The appellant contends that, without medication, his blood pressure would
either meet the criteria for a higher disability rating or, at a minimum, more nearly approximate the
criteria for a higher evaluation. Id. at 8-11 (citing 38 C.F.R. §§ 4.3 (2016), 4.7 (2016)). He further
asserts that the issue of what his blood pressure would be without medication is a question requiring
medical expertise and that the Board therefore violated Colvin v. Derwinski, 1 Vet. App. 171, 172
(1991), when it determined that he would not meet the criteria for a compensable rating were he not
taking medication without citing any supporting medical evidence. Id. at 5-7, 9.
Second, and in the alternative, the appellant argues that, even assuming that the Board was
permitted to consider the ameliorative effects of his medication, it erred by failing to discuss whether
his disability picture more nearly approximated the criteria for a higher disability rating. Id. at 13
(citing 38 C.F.R. § 4.7). Finally, he asserts that the Board clearly erred when it determined that he
did not have a history of diastolic pressure readings of 100 or more and, thus, that he did not satisfy
the criteria for a 10% disability rating under DC 7101. Id. at 14-15 (citing R. at 919).
With respect to the issue of referral for extraschedular consideration, the appellant contends
that the Board erred by failing to discuss whether referral was warranted. Id. at 16-19. In particular,
he argues that "the rating criteria, as interpreted by the Board, do not address [his] specific disability
picture," as there is "a medical question as to whether, but for his use of medication, he would have
compensable blood pressure readings." Id. at 18. He asks the Court to vacate and remand the
Board's decision. Id. at 19.
The Secretary responds that the Board did not err in denying entitlement to a compensable
disability for hypertension on either a schedular or extraschedular basis. Secretary's Br. at 7-28.
With respect to the effects of the appellant's blood pressure medication, the Secretary contends that
DC 7101 contemplates "a need for continuous medication to control the hypertension" and, thus, that
Jones is inapplicable. Id. at 15-17. He argues that the Board did not clearly err when it determined
that the appellant did not have diastolic blood pressure readings that were predominantly 100 or
higher, systolic blood pressure readings that were predominantly 160 or higher, or a history of
diastolic blood pressure predominantly 100 or more. Id. at 20; see 38 C.F.R. § 4.104, DC 7101
4
(2016). Moreover, the Secretary asserts that § 4.7 is inapplicable in this case, as "'there is no
question as to which evaluation shall be applied when a veteran does not satisfy all of the required
criteria of the higher rating but does satisfy all of the criteria of the lower rating.'" Secretary's Br.
at 21, 18-21 (quoting Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013)). Finally, the
Secretary argues that the Board was not required to discuss the issue of entitlement to referral for
extraschedular consideration, contending that the issue was neither raised by the appellant nor
reasonably raised by the record. Id. at 23-28. He asks the Court to affirm the Board's decision. Id.
at 28.
III. ANALYSIS
A. Schedular Evaluation
The appellant's arguments regarding the proper schedular evaluation for his hypertension
turn, in large part, on two related issues: first, whether the criteria in DC 7101 contemplate the
effects of medication, including whether Jones prohibits the Board from considering those effects
when evaluating hypertension; and, second, whether his disability picture, with or without
medication, "more nearly approximates" the criteria for a 10% disability rating than his current
noncompensable evaluation.
1. DC 7101, Jones, and the Effects of Medication
The Court will first turn to the issue of whether DC 7101 contemplates the effects of
medication. As the Court explained in Jones, "the Board may not deny entitlement to a higher
rating on the basis of relief provided by medication when those effects are not specifically
contemplated by the rating criteria." 26 Vet. App. at 63; see Massey v. Brown, 7 Vet. App. 204, 208
(1994) ("The Board's consideration of factors which are wholly outside the rating criteria provided
by the regulations is error as a matter of law."). Thus, if DC 7101 does not specifically contemplate
the effects of medication, the Board is required pursuant to Jones to discount the ameliorative effects
of medication when evaluating hypertension. Conversely, if DC 7101 does specifically contemplate
the effects of medication, then Jones is inapplicable. The Court holds that DC 7101 contemplates
the effects of medication and, therefore, that Jones does not apply.
"The starting point in interpreting a statute [or regulation] is its language." Good Samaritan
Hosp. v. Shalala, 508 U.S. 402, 409 (1993); see Smith v. Brown, 35 F.3d 1516, 1523 (Fed. Cir. 1994)
5
("The canons of construction of course apply equally to any legal text and not merely to statutes.").
"Where a statute's language is plain, and its meaning clear, no room exists for construction."
Gardner v. Derwinski, 1 Vet. App. 584, 587-88 (1991), aff'd sub nom. Brown v. Gardner, 513 U.S.
115 (1994). Statutes and regulations "must be considered as a whole and in the context of the
surrounding statutory [and regulatory] scheme." Gazelle v. McDonald, 27 Vet. App. 461, 464 (2016)
(citing King v. St. Vincent's Hosp., 502 U.S. 215, 221 (1991)).
Pursuant to DC 7101, a 60% disability rating is warranted for hypertension with "[d]iastolic
pressure predominantly 130 or more." 38 C.F.R. § 4.104, DC 7101. A 40% evaluation is warranted
for "[d]iastolic pressure predominantly 120 or more," and a 20% disability rating is warranted for
"[d]iastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more."
Id. A 10% evaluation is warranted in three circumstances: first, diastolic pressure predominantly
100 or more; second, systolic pressure predominantly 160 or more; or third, as a "minimum
evaluation for an individual with a history of diastolic pressure predominantly 100 or more who
requires continuous medication for control." Id. Note (1) to DC 7101 states, in part, that "the term
hypertension means that the diastolic blood pressure is predominantly 90mm. or greater." Id.
The criteria for compensable evaluations under DC 7101 thus contemplate two factual
alternatives. First, a veteran whose blood pressure is currently controlled by medication—i.e.,
whose blood pressure does not otherwise meet the criteria for a compensable evaluation—but who
has a history of diastolic pressure predominantly 100 or more is entitled to receive the minimum
compensable evaluation of 10%. Id. Second, a veteran whose blood pressure is currently elevated
to varying degrees is entitled to evaluations ranging from 10% to 60%. Id. Read together,
see Gazelle, 27 Vet. App. at 464, these two scenarios clearly contemplate the effects of medication:
either a veteran's blood pressure is controlled by medication, warranting a 10% evaluation if there
is a history of elevated systolic pressure, or it is not, in which case the actual blood pressure level
determines the disability rating.
The Court's analysis in Jones supports this reading of DC 7101. In that case, the Court held
that 38 C.F.R. § 4.114, DC 7319, which sets forth the rating criteria for irritable bowel syndrome,
did not contemplate the effects of medication. 26 Vet. App. at 63. The Court explained that "[t]he
Secretary has demonstrated . . . that he is aware of how to include the effect of medication as a factor
to be considered when rating a particular disability" and cited 38 C.F.R. § 4.71a, DC 5025
6
("Fibromyalgia"), as an example of a DC that does contemplate the effects of medication. Id. at 62.
DC 5025, like DC 7101, only explicitly references medication in its criteria for a 10% evaluation.
38 C.F.R. § 4.71a, DC 5025 (2016).
Although the appellant contends that the regulation, its implementing comments in the
Federal Register, and VA's M21-1 Adjudication Procedures Manual (M21-1) "show[] that the
Secretary intends to compensate veterans whose condition is 'brought under control' by medications
such that the condition no longer reaches blood pressure readings the rating criteria recognize as
compensable," Appellant's Br. at 12, his arguments are not persuasive. First, as discussed above,
the plain language of the rating criteria listed under DC 7101 demonstrates that this diagnostic code,
read as a whole, contemplates the effects of medication in assigning a disability rating for
hypertension. See Gazelle, 27 Vet. App. at 464; Gardner, 1 Vet. App. at 587-88.
Second, the sections of the Federal Register cited by the appellant5 do not alter the Court's
analysis. In 1997, the Secretary amended DC 7101. 62 Fed. Reg. 65,207, 65,215 (Dec. 11, 1997).
In doing so, he shifted the language providing a 10% evaluation on the basis of continuous
medication with a history of diastolic pressure predominantly 100 or more from a separate note into
the criteria for a 10% evaluation, as it "represents part of the evaluation criteria." Id. He explained
that "the evaluation for hypertension is based not on the amount of medication required to control
it, but on the level of control that can be achieved." Id. This explanation makes clear that the use
of medication is directly addressed and contemplated by the evaluation criteria under DC 7101.
5
To support his argument that the Board misinterpreted the criteria for a 10% disability rating under DC 7101
by failing to discount the ameliorative effects of his medication, the appellant quotes the Secretary's comment in the
Federal Register that "[w]hether a ten-percent evaluation is warranted when continuous medication is required is based
on a case-by-case assessment of each condition and the usual effects of treatment." Appellant's Br. at 12 (quoting
62 Fed. Reg. 65,207, 65,215 (Dec. 11, 1997)). The appellant thus creates the impression that the Secretary's
consideration of the need for continuous medication under DC 7101 may vary from case to case depending upon the
circumstances of a particular claimant's condition. However, when read in context, it is clear that the Secretary is instead
explaining why he chose to include a minimum rating based on continuous medication only for certain DCs, including
DC 7101. See 62 Fed. Reg. at 65,215.
To the extent that the appellant also cites the Federal Register to support his contention that DC 7101 does not
simultaneously require both the use of medication and current diastolic blood pressure readings of predominantly 100
or more, see Appellant's Br. at 12, there is no dispute over this issue, as the Secretary acknowledges that the minimum
compensable rating for hypertension requires only a history of elevated diastolic pressure, as opposed to currently
elevated diastolic pressure, see Secretary's Br. at 9.
7
Third, although the appellant cites the predecessor to the M21-1 as requiring VA adjudicators
to "'start with . . . the readings taken as part of a . . . diagnostic workup period leading to the
prescription of medication'" as evidence that DC 7101 does not contemplate the effects of
medication, Appellant's Br. at 12 (quoting VA Adjudication Procedures Manual Rewrite (M21-
1MR) pt. III, subpt. iv, ch. 4, § E.20.e) (emphasis removed), it is not clear whether that provision
relates to DC 7101 as a whole or merely to whether a veteran whose blood pressure is controlled by
medication satisfies the criteria for a 10% evaluation. The current M21-1, however, includes the
cited language as part of its instructions on how to evaluate whether a veteran's "past diastolic
pressure (before medication was prescribed) was predominantly 100 or greater" when "current
predominant blood pressure readings are non-compensable." M21-1, pt. III, subpt. iv, ch. 4, § E.1.e.
In any event, the appellant fails to explain how his citation to the M21-1's predecessor, which
focuses upon the relevant period for determining whether a claimant has a history of blood pressure
readings, supports his broader argument that the Secretary intended to compensate all veterans
whose blood pressure readings are controlled by medication. See Locklear v. Nicholson, 20
Vet. App. 410, 416 (2006) (holding that the Court will not entertain underdeveloped arguments).
In sum, as the plain language of DC 7101 contemplates the effects of medication, and
because the Secretary's comments in the Federal Register at the time of its 1997 amendment support
this reading, the Court holds that DC 7101 contemplates the effects of medication and, thus, that
Jones is not applicable. Accordingly, the Court rejects the appellant's arguments that the Board
erred when it failed to consider whether he would be entitled to a compensable rating if he were not
taking medication. See Appellant's Br. at 8-11. As the appellant's contentions that a medical
opinion was required to properly discount the effects of his medication and that the Board violated
Colvin when it relied on its own medical judgment are premised on his erroneous reading of DC
7101, id. at 5-7, 9, the Court rejects those arguments, as well.
2. The Appellant's Remaining Arguments
Having determined that Jones does not apply and that the Board did not err by considering
the ameliorative effects of the appellant's medication, the Court will address the appellant's
remaining arguments that the Board erred when it found that he did not more nearly approximate
the criteria for a 10% evaluation and did not have a history of diastolic pressure predominantly 100
or more. See Appellant's Br. at 13-15.
8
Turning first to the appellant's contention that he does, in fact, have a history of diastolic
pressure predominantly 100 or more, id. at 15, the Court holds that the Board did not clearly err
when it determined that he did not, R. at 8; see Hood v. Shinseki, 23 Vet. App. 295, 299 (2009) ("The
Court reviews factual findings under the 'clearly erroneous' standard such that it will not disturb a
Board finding unless, based on the record as a whole, the Court is convinced that the finding is
incorrect."). In support of his argument, the appellant cites medical records documenting six blood
pressure readings prior to when he began taking medication. Appellant's Br. at 15 (citing R. at 919).
Those readings, all dated March 2, 2009, are 144/92, 142/86, 128/88, 138/80, 156/100, and 148/96.
R. at 919. Although there is one reading demonstrating diastolic pressure of 100, that single reading
does not demonstrate clear error in the Board's finding that the appellant did not have a history of
diastolic pressure predominantly 100 or more, as required by the rating criteria. See 38 C.F.R.
§ 4.104, DC 7101. Rather, to accept the appellant's argument would be to omit the key word
"predominantly" from the rating criteria, which the Court cannot do. See 38 U.S.C. § 7252(b) ("The
Court may not review the schedule of ratings for disabilities . . . or any action of the Secretary in
adopting or revising that schedule."); Moskal v. United States, 498 U.S. 103, 109 (1990) (reiterating
"the established principle that a court should 'give effect, if possible, to every clause and word of a
statute'" (quoting United States v. Menasche, 348 U.S. 528, 538-39 (1955))); see Wingard v.
McDonald, 779 F.3d 1354, 1356–57 (Fed. Cir. 2015) (discussing the Court's inability to review the
schedule of ratings for disabilities).
Similarly, although the appellant contends that the Board erred by failing to consider whether
he more nearly approximated the criteria for a 10% evaluation, Appellant's Br. at 13-16, the Court
is not persuaded. See Hilkert v. West, 12 Vet. App. 145, 151 (1999) (en banc) ("An appellant bears
the burden of persuasion on appeals to this Court."), aff'd per curiam, 232 F.3d 908 (Fed. Cir. 2000)
(table). To qualify for a 10% evaluation under DC 7101, a veteran must satisfy one of three
alternatives: first, current diastolic pressure predominantly 100 or more; second, current systolic
pressure predominantly 160 or more; or third, a history of diastolic pressure predominantly 100 or
more with blood pressure controlled by continuous medication. 38 C.F.R. § 4.104, DC 7101.
"Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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.
9
In its decision, the Board did not specifically discuss whether the appellant satisfied either
the first or second alternative for a 10% evaluation, but it determined that he had "diastolic pressure
predominantly less than 100, and systolic pressure predominantly less than 150." R. at 8. With
respect to the third alternative, the Board acknowledged that the appellant "clearly requires
continuous medication" but found that "the preponderance of the evidence shows he does not have
a history of diastolic pressure predominantly 100 or more," and thus that he "more nearly
approximated the assigned noncompensable rating."6 R. at 9 (citing, inter alia, 38 C.F.R. § 4.7).
Although the appellant argues that he may satisfy the first or second alternatives were the
Board to discount the effects of his medication, Appellant's Br. at 15-16, the Court has already
considered and rejected that argument above. With respect to the third alternative, the Court is not
persuaded that the Board erred when it determined that his diastolic pressure history more nearly
approximated the noncompensable level. As noted above, the Board specifically determined that
the appellant did not satisfy the criteria for a 10% evaluation. R. at 9. Moreover, the Court is not
convinced that the blood pressure readings cited by the appellant "more closely approximate"
diastolic pressure of pressure 100 or more, as opposed to diastolic pressure predominantly 90 or
more as required by a noncompensable evaluation. See 38 C.F.R. § 4.104, DC 7101, Note (1)
(defining hypertension for VA purposes as "diastolic blood pressure [that] is predominantly 90 mm.
or greater"). In short, the Board properly determined that there was no question as to which
evaluation applied, and § 4.7 therefore was not for application. See 38 C.F.R. § 4.7.
Ultimately, the Court is not persuaded that the Board clearly erred when it determined that
the appellant was not entitled to a compensable evaluation for hypertension under DC 7101. See
Johnston v. Brown, 10 Vet. App. 80, 84 (1997) (the Board's assignment of a disability rating is a
6
The M21-1 specifically prohibits adjudicators from assigning a 10% evaluation if a veteran meets only one
of the two criteria for the third alternative:
Do not assign a 10[%] evaluation based upon a showing of one of the two conjunctive criteria above
by invoking the benefit of the doubt rule. . . . When either criterion is simply not shown (for example,
the claimant is using prescribed anti-hypertensive medication but diastolic pressure has never been
predominantly 100 or greater) the evidence is not in relative equipoise on whether a 10-percent
evaluation is appropriate and the disability picture does not more nearly approximate the 10-percent
criteria.
M21-1, pt. III, subpt. iv, ch. 4, § E.1.e. The M21-1 acknowledges, however, that § 4.7 "may be applicable to whether
the evidence supports each criterion." Id.
10
question of fact, which the Court reviews under the "clearly erroneous" standard). Further, as the
Board's decision regarding the proper schedular evaluation is understandable and facilitates judicial
review, the Court holds that the Board provided an adequate statement of reasons or bases to support
that determination. See 38 U.S.C. § 7104(d)(1); Allday v. Brown, 7 Vet. App. 517, 527 (1995).
B. Extraschedular Referral
As a final matter, the Court rejects the appellant's contention that the Board erred by failing
to address whether referral for extraschedular consideration was warranted. Appellant's Br. at 16-19.
"[T[he issue of whether referral for extraschedular consideration is warranted must be argued by the
claimant or reasonably raised by the record." Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); see
Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (the Board is required to consider all issues raised
by a claimant or reasonably raised by the evidence of record), aff'd sub nom. Robinson v. Shinseki
557 F.3d 1355 (Fed. Cir. 2009). The Board is required to discuss referral "[w]here there is evidence
in the record that shows exceptional or unusual circumstances," Colayong v. West, 12 Vet. App. 524,
536 (1999), or where "the evidence of record suggests that a schedular rating may be inadequate,"
Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed.
Cir. 2009). "Where, however, [38 C.F.R.] '§ 3.321(b)(1) [is] neither specifically sought by [the
claimant] nor reasonably raised by the facts found by the Board,' the Board is not required to discuss
whether referral is warranted." Yancy, 27 Vet. App. at 494 (quoting Dingess v. Nicholson,
19 Vet. App. 473, 499 (2006), aff'd, 226 F. App'x 1004 (Fed. Cir. 2007)).
The appellant does not contend that he specifically raised this issue below. Accordingly, for
the Board to have erred by failing to discuss referral for extraschedular consideration, that issue must
have been reasonably raised by the record. It was not. Although the appellant asserts that "the
rating criteria, as interpreted by the Board, do not address [his] specific disability picture," as there
is "a medical question as to whether, but for his use of medication, he would have compensable
blood pressure readings," Appellant's Br. at 18, the Court is not persuaded. Rather, as DC 7101
explicitly contemplates the effects of medication, the use of medication cannot constitute an unusual
disability picture, and the question of what the appellant's current disability would be absent his
medication is not relevant. See 62 Fed. Reg. at 65,215 ("[T]he evaluation for hypertension is based
not on the amount of medication required to control it, but on the level of control that can be
achieved.").
11
As referral for extraschedular consideration was neither argued by the appellant nor
reasonably raised by the record, the Court holds that the Board did not err in failing to discuss that
issue. See Yancy, 27 Vet. App. at 494. Accordingly, the Court will affirm that part of the Board's
decision denying entitlement to a compensable disability evaluation for hypertension.
IV. CONCLUSION
As DC 7101 explicitly contemplates the ameliorative effects of medication, the Board did
not err when it considered the effects of the appellant's medication when evaluating his
hypertension. Moreover, the Board did not clearly err when it determined that the appellant did not
have a history of diastolic pressure predominantly 100 or more or when it determined that his
hypertension did not more nearly approximate the criteria for a 10% evaluation. Finally, as referral
for extraschedular consideration was not raised by the appellant below or reasonably raised by the
record, the Board did not err by failing to discuss that issue.
Therefore, upon consideration of the foregoing analysis, the record on appeal, and the parties'
briefs, that part of the Board's June 4, 2014, decision denying entitlement to an initial compensable
disability rating for hypertension is AFFIRMED. The appeal is DISMISSED as to the issues of
entitlement to service connection for a neck disorder, bilateral hearing loss, tinnitus, and sinusitis,
and entitlement to increased initial disability ratings for left shoulder strain, right carpal tunnel
syndrome, and choroidal nevus of the right eye.
KASOLD, Judge, with whom SCHOELEN, Judge, joins, concurring in part: I agree with the
result reached in today's decision. The Board's analysis and application of diagnostic code (DC)
7101 was proper, and the Board decision on appeal should be affirmed. I write separately, however,
because Mr. McCarroll's argument that Jones v. Shinseki requires remand on the facts in his case
illustrates that the Jones holding–i.e., that "the Board may not deny entitlement to a higher rating
on the basis of relief provided by medication when those effects are not specifically contemplated
by the rating criteria," Jones v. Shinseki, 26 Vet. App. 56, 63 (2012)–is erroneous and should now
12
be overturned. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) ("Only the en banc Court may
overturn a panel decision.").
Jones is fairly cited by Mr. McCarroll for the proposition that it is impermissible to deny a
compensable rating when the veteran raises the possibility that his symptoms would rise to a
compensable level if he were not taking his required medication. See Appellant's Brief (Br.) at 10
("[I]f the only reason Mr. McCarroll's blood pressure readings were noncompensable was because
of the therapeutic effects of his medication[], it would be impermissible to deny him a compensable
rating based on those therapeutic effects."); see Jones, supra. Although Jones has been artfully
distinguished by the majority opinion being issued today, the better course is to recognize that the
Jones holding is predicated on a misunderstanding of the rating schedule and a failure to appreciate
the ramifications of that holding and is therefore wrongly decided. It should be overturned.
The Rating Schedule
The essence of the rating schedule is that veterans are compensated for their symptoms and,
specifically, how those symptoms would, on average, impair a person's earning capacity. 38 U.S.C.
§ 1155 ("The Secretary shall adopt and apply a schedule of ratings of reductions in earning capacity
from specific injuries or combination of injuries. The ratings shall be based, as far as practicable,
upon the average impairments of earning capacity resulting from such injuries in civil
occupations."); 38 C.F.R. § 4.2 (2016) (noting that it is crucial for the rating to "accurately reflect
the elements of disability present"); 38 C.F.R. § 4.10 (2016) ("The basis of disability evaluations
is the ability of . . . [an] organ of the body to function under the ordinary conditions of daily life
including employment."); 38 C.F.R. § 3.321(b)(1) (2016) ("Ratings shall be based as far as
practicable[] upon the average impairments of earning capacity[.]").
To accomplish the task of compensating a veteran based on the average impairment in
earning capacity, the diagnostic codes in the disability rating schedule ask what the veteran's
symptoms are, compared to a list of symptoms of ascending severity in the rating schedule, which
this Court is without authority to second-guess. See 38 U.S.C. § 7252(b) ("The Court may not
review the schedule of ratings for disabilities adopted under section 1155 of this title or any action
of the Secretary in adopting or revising that schedule."); Wanner v. Principi, 370 F.3d 1124, 1130-31
(Fed. Cir. 2004) ("The Secretary's discretion over the [rating] schedule, including procedures
followed and content selected, is insulated from judicial review with one recognized exception
13
limited to constitutional challenges."). The rating schedule does not ask what the symptoms could
be, if not for various positive influences in a veteran's life, including medication.
Mr. McCarroll’s arguments amply illustrate the distortion of the rating schedule created by
Jones. He argues that his blood pressure readings were "skewed" by the ameliorative effects of his
medication. Appellant's Br. at 11. But, the readings were not skewed. The introduction of
medication did not "taint" the results or render them inaccurate or misleading. The readings reflect
the actual level of Mr. McCarroll's blood pressure at the times the readings were taken, and they
therefore reflect "the elements of disability present" at those times. 38 C.F.R. § 4.2. Because taking
blood pressure medication is not an unusual phenomenon for people with high blood pressure, the
readings also reflect the condition of Mr. McCarroll's body under "the ordinary conditions of life."
38 C.F.R. § 4.10. Otherwise stated, nothing in the rating schedule warrants subtracting whatever
positive influences medication has on Mr. McCarroll's blood pressure.
Flaw in Jones
A review of Jones reflects that its holding was predicated on an inaccurate premise.
Specifically, the Court stated in Jones that the Secretary "demonstrated in other DCs that he is aware
of how to include the effect of medication as a factor to be considered when rating a particular
disability." 26 Vet. App. at 62. The Court then pointed to two other DCs (5026 and 6602) that the
Court stated require VA adjudicators to expressly consider the ameliorative effects of medication.
Id. However, neither of the two "other DCs" cited by the panel in Jones requires the Board to
consider the "ameliorative effects" of medication. In DC 5025, a 10% disability rating is provided
for fibromyalgia where symptoms "require continuous medication for control." 38 C.F.R. § 4.71a,
DC 5025 (2016). In DC 6602, a 10% disability rating is provided for bronchial asthma if the record
shows, inter alia, "intermittent inhalational or oral bronchodilator therapy." 38 C.F.R. § 4.97, DC
6602 (2016). These diagnostic codes require only that the Board consider the fact of medication
usage, as a proxy for the seriousness of the condition; they do not require that the Board consider
any "ameliorative effect."
Indeed, although some diagnostic codes mention the fact of medication usage as a rating
criterion, none require the Board to make any affirmative use of information about the "ameliorative
effects" of the medication. See, e.g., 38 C.F.R. § 4.79, DC 6012 (2016) (DC for angle-closure
glaucoma establishes a 10% rating "if continuous medication is required"); 38 C.F.R. § 4.88b, DC
14
6351 (2016) (DC for HIV-related illness allows a 30% rating with certain symptoms if the veteran
is "on approved medication(s)"); 38 C.F.R. § 4.118, DC 7806 (2016) (DC for dermatitis or eczema
provides ratings based, in part, on the type of medication used, including a 60% rating when there
is "constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive
drugs required during the past 12-month period").7
In sum, nothing about the rating schedule supports the Jones conclusion that the Board must
affirmatively rule out any ameliorative effects of medication when assessing a veteran's disability
picture.
Unacceptable Ramifications
That the Jones holding should be overturned becomes even clearer when one considers the
unacceptable consequences that flow inexorably from it. Cf. United States v. Dixon, 509 U.S. 688,
709-10 (1993) (noting that an earlier decision of the Court should be overturned because it was
"wrong in principle," had "proved unstable in application," and was "a continuing source of
confusion"). The requirement that the Secretary "may not consider the relief afforded by [a
veteran's] medication when" applying the rating schedule, as Jones demands, See Jones, 26 Vet. App.
at 63, invites medical speculation in trying to guess what a veteran's symptoms might be without the
medication, or medical malpractice in the cessation of medication so that the veteran's symptoms
without medication might be recorded. The former invites non-helpful guesswork by medical
practitioners, see Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2005) (medical opinions that are
speculative have "little probative value"), and the latter raises, at a minimum, serious ethical
concerns that no court should encourage. That Jones essentially requires the Board to consider
7
Similar to the DC in Jones, DC 7101 does not require the Board to take into account any ameliorative effects
of medications; the Board is to consider only the fact that the veteran may have particular blood pressure readings while
taking "continuous medication for control." 38 C.F.R. § 4.104, DC 7101 (2016). Therefore, although I agree with
today's ultimate decision, I disagree with the statement that DC 7101 asks the Board to consider the "effects" of
medication. Ante at 6. The Board acted properly in denying a compensable rating because the DC does not contemplate
the effects of medication and the Board did not take any such effects into account. Mr. McCarroll's diastolic pressure
readings are not predominantly 100 or more, his systolic pressure readings are not predominantly 160 or more, and he
has never had a history of diastolic pressure predominantly 100 or more. Therefore, under the plain language of the
regulation, whether he "requires continuous medication for control" or not, he does not meet the requirements for a 10%
rating. See § 4.104, DC 7101; see also Tropf v. Nicholson, 20 Vet. App. 317, 320 (2006) ("On review, if the meaning
of the regulation is clear from its language, then that is 'the end of the matter.'" (quoting Brown v. Gardner, 513 U.S. 115,
120 (1994))). This was precisely the finding reached by the Board in this case. See Record at 4 (Board finding that
"[t]he Veteran's hypertension has not manifested with diastolic pressure predominantly 100 or more, with or without
medication; or, systolic pressure predominantly 160 or more throughout the initial rating period").
15
whether a medical examination is required to determine how serious a veteran's symptoms would
have been in an alternate reality in which he or she was not taking his or her required medication
should alone demonstrate the fallacy of the Jones holding.
Closing
I concur that there was no clear error in the Board's analysis for the reasons stated in today's
controlling opinion, but, for the reasons stated above, the Court, now sitting en banc, should declare
the Jones holding wrongly decided and overrule it. See Bethea, supra.
HAGEL, Senior Judge, with whom GREENBERG, Judge, joins, dissenting: I disagree with
the majority's view that the Board did not err when it considered the ameliorative effects of Mr.
McCarroll's medication by reading 38 C.F.R. § 4.104, Diagnostic Code 7101, as a whole, to
determine that the diagnostic code contemplates the ameliorative effects of medication. The
majority does not explain how it arrives at the conclusion that, because one part of the rating criteria
under Diagnostic Code 7101 contemplates the ameliorative effects of medication, it necessarily
follows that the entire diagnostic code contemplates the ameliorative effects of medication. Ante
at 7.
The majority cites Jones v. Shinseki, 26 Vet. App. 56, 60 (2012), in which the Court held that
the Board erred when it considered the effects of medication that were not adequately contemplated
by the rating criteria for irritable bowel syndrome. The Court in Jones cited the language of the
rating criterion for a 10% disability rating under § 4.71a, Diagnostic Code 5025 (fibromyalgia), as
an example of how the Secretary considers the ameliorative effects of medication. Id. at 63. The
entirety of that rating criterion, which remains unchanged since Jones, for a 10% disability rating
for fibromyalgia is for symptoms "[t]hat require medication for control." 38 C.F.R. § 4.71a,
Diagnostic Code 5025 (2016). In this case, the plain language of Diagnostic Code 7101
demonstrates that the Secretary included three alternatives to obtain a 10% disability rating, and
only one contemplates the ameliorative effects of medication. 38 C.F.R. § 4.104, Diagnostic Code
7101 (2016) (10% disability rating requires "Diastolic pressure predominantly 100 or more, or;
systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a
history of diastolic pressure predominantly 100 or more who requires continuous medication for
16
control.") (emphasis added); see Tropf v. Nicholson, 20 Vet. App. 317, 322 n.1 (2006) ( "[A]
functioning system of laws must give primacy to the plain language of authorities."). Therefore, it
is unclear how the majority can arrive at the conclusion that, given the plain language of Diagnostic
Code 7101, the ameliorative effects of medication can be considered for all three alternatives to
obtain a 10% disability rating. Accordingly, I believe that Jones applies to this case, and the Board
erred when it considered the ameliorative effects of Mr. McCarroll's medication under the first two
alternatives of the rating criteria for a 10% disability rating under Diagnostic Code 7101.
The majority also cites to the Federal Register where the Secretary amended Diagnostic
Code 7101. Ante at 7. The majority quoted the Secretary where he moved the rating criteria, "a
history of diastolic pressure predominantly 100 or more and continuous medication is required,"
from a separate note in Diagnostic Code 7101 to the rating criteria for a 10% disability rating. Id.
citing 62 Fed. Reg. 65, 207, 65, 215 (Dec. 11, 1997). The majority concludes that the Secretary's
explanation "makes clear that the use of medication is directly addressed and contemplated by the
evaluation criteria under DC 7101." Ante at 7. However, the Secretary's final rule only discusses
the third alternative for a 10% disability rating under Diagnostic Code 7101 and does not discuss
the other two alternatives, which do not consider the ameliorative effects of medication. See 62 Fed.
Reg. at 65,215. Therefore, I believe that the ameliorative effects of medication should only be
considered under the third alternative under Diagnostic Code 7101, that is, whether a veteran has
a history of diastolic pressure predominantly 100 or more, who requires continuous medication for
control.
The majority also rejects Mr. McCarroll's contention, without any explanation, that a medical
opinion was required to discount the ameliorative effects of medication and the Board violated
Colvin v. Derwinski, 1 Vet. App. 171, 172 (1990) (holding that the Board "must consider only
independent medical evidence to support [its] findings rather than provide [its] own medical
judgment in the guise of a Board opinion"). Ante at 8. Here, the Board found that Mr. McCarroll's
"hypertension has not manifested with diastolic pressure predominantly 100 or more, with or without
medication; or systolic pressure predominantly 160 or more throughout the initial rating period."
R. at 4 (emphasis added). The Board made its own medical finding by considering the ameliorative
effect of medication on Mr. McCarrolls's current diastolic and systolic pressure or, in other words,
the first two alternatives of Diagnostic Code 7101. See Jones, 26 Vet. App. at 63; Colvin, 1 Vet. App.
17
at 172. Mr. McCarroll was prescribed medication for his hypertension while in service, R. at 757
(April 2009 prescription), he filed his claim for benefits for hypertension while in service, and a VA
regional office granted his claim and assigned a noncompensable rating on September 1, 2009, the
date after his separation from service, R. at 683-84 (October 2009 rating decision). Further, at the
November 2010 VA medical examination in which the examiner took Mr. McCarroll's blood
pressure readings, the examiner noted that Mr. McCarroll's medication dosage had been increased
from his last prescription. R. at 585. Clearly, the Board should have considered that medication was
at least a factor affecting Mr. McCarroll's blood pressure readings.
The Board, however, considered Mr. McCarroll's blood pressure readings from the
November 2010 VA medical examination while he was on medication when it denied a compensable
disability rating. R. at 8. In doing so, I believe the Board improperly considered the ameliorative
effects of medication when evaluating Mr. McCarroll's hypertension under the first two alternatives
of the rating criteria for a 10% disability rating. Because Mr. McCarroll was under medication at
the time of the examination, I also believe that the Board should have discussed whether a medical
opinion is required to address the question of what Mr. McCarroll's diastolic and systolic pressure
would be, but for the use of medication. In my judgment, a medical examiner would be in the best
position to review Mr. McCarroll's medical record to make some determination as to his diastolic
and systolic blood pressure without medication.
This case presented the issue where a veteran is prescribed medication for a disability and
the diagnostic code for that disability requires specifically measured medical readings to determine
compensability. In this case, the Board found McCarroll's disability noncompensable and clearly
did not consider that he was on medication since service when it used his blood pressure readings
to support its finding. Therefore, for the reasons stated above, I would vacate the June 4, 2014,
Board decision and remand the matter for the Board to provide adequate reasons or bases for its
decision, which would limit its consideration of the ameliorative effects of Mr. McCarroll's
medication only to the third alternative for a 10% disability rating under Diagnostic Code 7101 and,
at the very least, to discuss whether a medical opinion is required to determine Mr. McCarroll's
diastolic and systolic pressure absent his use of medication.
18