BENIGN NEOPLASMS OF THE DIGESTIVE SYSTEM

STEVEN D. REISS · 2026 · Case ID: A26038542

DENIED

Summary

The veteran, an Army veteran who served from January 2004 to May 2012, including combat service in Iraq, appeals the denial of an initial compensable rating for service-connected bilateral gynecomastia. The veteran also sought a temporary total rating based on a May 2021 surgery. The Board reviewed the evidence of record, noting the veteran's combat service and awards, including the Combat Infantryman Badge and Iraq Campaign Medal. The veteran's claim for a higher rating was based on a bilateral simple mastectomy performed in May 2021. The Board considered the rating criteria for gynecomastia, which is rated by analogy under Diagnostic Code 7626 for breast conditions. The VA examination in May 2021 indicated the gynecomastia resulted from medication and led to a bilateral simple mastectomy. The examiner found no functional impairment or need for further surgery. The Board found that the evidence did not support a compensable rating, as there was no evidence of functional impairment or impact on work. The veteran's claim for a temporary total rating was also denied, as the surgery predated the effective date of service connection and did not involve hospitalization or convalescence of at least 21 days. Therefore, the Board denied entitlement to a compensable rating for bilateral gynecomastia.

Rationale

No evidence of functional impairment; No evidence of impact on work; Surgery did not warrant higher rating

Service Branch

ARMY

Special Benefit

TEMPORARY TOTAL (§4.30)

Diagnostic Code

7631

Docket No.

211008-197112

Full Decision Text

Citation Nr: A26038542
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 211008-197112
DATE: April 24, 2026

ORDER

Entitlement to an initial compensable rating for service-connected bilateral gynecomastia is denied.

FINDING OF FACT

The Veteran's bilateral gynecomastia has resulted in a simple total mastectomy that is best characterized as a local excision without significant alteration of size or form and has not required hospitalization or convalescence of at 21 days since service connection was established.

CONCLUSION OF LAW

The criteria for a compensable rating for bilateral gynecomastia have not been met. 38 U.S.C. §§ 1154(a), 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.29, 4.30, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 7631.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from January 2004 to May 2012, including combat service in Iraq, where the Veteran was stationed from October 2005 to February 2006, January 2007 to March 2008, and from August 2009 to July 2010. The Veteran's decorations include the Combat Infantryman Badge and the Iraq Campaign Medal.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2021 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).

In the October 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected to have a hearing before a Veterans Law Judge.

A hearing was scheduled for May 13, 2025; however in April 2025, the Veteran's attorney submitted written correspondence indicating that they wished to withdraw their hearing request. See April 2025 BVA Hearing withdrawal. Therefore, the Board may only consider the evidence of record at the time of the June 2021 rating decision on appeal, as well as any evidence submitted by the Veteran or his attorney within 90 days following receipt of the withdrawal of the hearing request. 38 C.F.R. § 20.302(b).

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

As a final preliminary matter, the Board notes that the Veteran filed a VA Form 10182 in November 2021 challenging a September 2021 rating decision that denied entitlement to a temporary total evaluation for bilateral gynecomastia because of treatment for a service-connected condition requiring convalescence due to surgery or for hospitalization for more than 21 days based on a March 2021 report that he submitted on July 22, 2021. Because the Veteran initially submitted that report to VA in May 2021, and because a temporary total rating is a rating issue within the period on appeal, the Board will consider whether a temporary total rating is warranted based on the surgery.

In doing so, the Board acknowledges that based on the Veteran's resubmission of this March 2021 medical report, the RO denied entitlement to a temporary total rating in a September 2021 rating decision, for which the Veteran a VA Form 10182 in November 2021.

1. Entitlement to an initial compensable rating for service-connected bilateral gynecomastia

The Veteran contends that he is entitled to a higher rating for gynecomastia, to include a temporary total rating based on March 2021 surgery. For the reasons stated below, the Board finds that a higher rating is not warranted.

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. § Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the specified findings; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability 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.

It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25.

In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20.

Gynecomastia is not explicitly listed in the Rating Schedule. As such, the first task before the Board is to determine what Diagnostic Code should be considered for a rating by analogy. The VA RO has assigned Diagnostic Code 7631, based on benign neoplasms of the breast and other injuries of the breast.

Diagnostic Code 7631 considers impairment of function as related to scars. Service connection is also in effect and the Veteran is separately rated under a diagnostic code for the scars he has resulting from surgery. Diagnostic Code 7631 also considers impairment of function as related to lymphedema and disfigurement, but the evidence does not show functional impairment due to either. Finally, Diagnostic Code 7631 contemplates a rating by analogy to Diagnostic Code 7626.

Under Diagnostic Code 7626, a radical mastectomy warrants a 50 percent rating for one breast or 80 percent for both breasts; a modified radical mastectomy warrants a 40 percent rating for one breast or 60 percent for both breasts; a simple mastectomy or a wide local excision with significant alteration of size or form warrants a 30 percent rating for one breast or 50 percent for both breasts; and a wide local excision without significant alteration of size or form warrants a noncompensable rating for both breasts. 38 C.F.R. § 4.116 Diagnostic Code 7626. A radical mastectomy means removal of the entire breast, underlying pectoral muscles, and regional lymph nodes up to the coraclavicular ligament. A modified radical mastectomy means removal of the entire breast and axillary lymph nodes (in continuity with the breasts) but the pectoral muscles are left intact. 38 C.F.R. § 4.116, DC 7626 Notes 1, 2.

Records show that in May 2021 the Veteran underwent a bilateral gynecomastia surgery with removal of breast tissue. The medical records do not suggest that the Veteran has undergone a radical or modified radical mastectomy, and the Veteran has not reported such treatment.

Here, the Board finds that a compensable rating for the Veteran's bilateral gynecomastia is not warranted. There is no evidence that the Veteran's condition causes any impairment of function and there is also no evidence that it impacts the Veteran's ability to work.

The Veteran underwent a VA examination to assess his bilateral gynecomast
left intact. 38 C.F.R. § 4.116, DC 7626 Notes 1, 2.

The Veteran underwent a VA examination to assess his bilateral gynecomastia in May 2021 where he noted that he developed gynecomastia as a result of medication the Veteran was taking for his service-connected disability and that resulted in a bilateral simple mastectomy in May 2021. He indicated his current symptoms were pain and tenderness.

In light of the foregoing, the Board finds that the probative evidence does not support a compensable rating for the Veteran's bilateral gynecomastia. The VA examiners found that the Veteran's bilateral gynecomastia has not resulted in any need for further surgery, tissue loss, or functional impairment. Neither the VA examination reports nor any of the Veteran's VA or private treatment records indicate that the Veteran's bilateral gynecomastia manifested in chronic residual symptoms or a need for further surgeries of the breast other than the 2021 surgery to remove the excess breast tissue.

The Board has considered the Veteran's statements regarding the severity of his disability but finds that his lay account is outweighed by the VA examination findings.

As a final matter, the Board acknowledges the Veteran's contention that a temporary total rating is warranted based on the March 2021 surgery. Here, however, there is no indication that the Veteran was hospitalized or required convalescence for at least 21 days and the surgery predates the effective date of service connection, i.e., it was prior to April 16, 2021. As such, entitlement to a temporary total rating is not warranted.

Accordingly, entitlement to a compensable rating is denied for the Veteran's service-connected bilateral gynecomastia. The appeal is denied.

STEVEN D. REISS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Woehlke, V.

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.

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