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Monday, March 10, 2014

Pyramiding: The Dos and Don’ts of Combining Conditions

Trying to figure out what symptoms/conditions should be rated for military disability can be very complicated. In addition to the qualifications for each condition, there are also many principles that change how the rules of the VASRD are applied in different circumstance. 

One of these wonderful little principles is called “Pyramiding”. Trying to figure out exactly how this principle works in different circumstances can definitely make me feel like this guy.

Let’s start my explanation with a parable, of sorts. You are building a pyramid, and you have a single big block of stone that is the same size as all the other stones. It needs to be added to the pyramid. Now, you wouldn’t cut the stone in half and then put half of it on top of the other before adding it; it would no longer be the right size. Plus, each half of the stone is not a distinct and separate thing. They both make up the same big stone. You can even give them two different names, but they are still the same big stone. Similarly, you wouldn’t separate the symptoms of a single condition, give them two different names and then say that they are indeed distinct and separate. They are still the exact same condition. (Wow, this parable is a bit rocky, no pun intended, and I completely lost the valuable take-home message. Let’s see if I can do better.)

The basic rule of pyramiding is that you cannot rate a single symptom more than once. There are many different conditions that can cause the same symptoms. If you have two different conditions that cause the exact same symptoms, then only one of them can be rated. In cases like this, you’d pick the condition that gives you the higher rating. For example, if you have tendonitis in your elbow that limits how much you can move it, and you have a muscle condition that affects the muscles that move the elbow and also causes limited motion in the same elbow, then only one can be rated since they both cause the limited motion in the elbow. You don’t get two ratings—one for the muscle and one for the tendonitis—just one rating. Pick the condition that gives the highest rating.

Now the symptoms have the be the EXACT same for this rule to apply. If you have two back conditions, one causes pain down the arms, and the other causes pain down the legs, they can be rated separately since the symptoms are NOT the same. They affect two totally different areas of the body even though they are both back conditions. Make sense? Hope so, cause it’s about to get worse.

When there are many symptoms involved, and not all are shared, it gets a lot more complicated. Since you can’t rate the same symptom twice, you have to separate the shared ones. The easiest way to explain this is with an example. In this example, don't worry about the technical language: you don't need to understand what everything means to get the point of pyramiding.

There are two conditions:

An arteriovenous fistula is a condition where a new passageway is created between an artery and a vein. It causes the heart to work harder to get blood flowing. For this example, let’s say that it causes the following symptoms: swelling in the arms and right ventricular hypertrophy in the heart.

Chronic bronchitis is a condition where the bronchi in the lungs swell and restrict how much air the lungs can take in. Let’s say it causes an FEV-1 lung test measurement of 63%, a DLCO (SB) lung test measurement of 71%, and right ventricular hypertrophy.

Here’s the list of symptoms:

Fistula: right ventricular hypertrophy, arm swelling
Bronchitis: right ventricular hypertrophy, FEV-1 63%, DLCO (SB) 71%

Both conditions have some of their own unique symptoms, but they also share the most severe symptom: right ventricular hypertrophy. The hypertrophy can only be used for one of the conditions, whichever would benefit the most from it, meaning it would get a much higher rating.

So let’s look at the ratings for both conditions with their symptoms.

For the arteriovenous fistula, the condition with the hypertrophy would rate 60%. Without the hypertrophy, it would rate 20%. 

For the chronic bronchitis, it would rate 100% with the hypertrophy, and 30% without it.

A 100% rating is clearly much better than 60%, so in this case, the bronchitis would be rated 100% with the hypertrophy. The other condition can still be rated, but not with the hypertrophy, so it would be rated 20%.

Pyramiding can get very complicated, but take it step by step. Start by listing symptoms, and then see how the different conditions are rated. If they have their own symptoms, they can be rated separately.

Just remember: each symptom can only be rated once.


  1. Sir, I have been diagnosed with degenerative arthritis of the lumbar spine with a 20 percent disability rating. A neurosurgeon assessed me as well and said I had neuropathy/radiculopathy in the left leg and input it in ALTA. Can this be "pyramided" off the lumbar ailment and add up to 30 percent?

  2. Also, when the VA Doc did my ROM, he only did forward flexion, and not side or back. I can dispute this as well, correct?

    1. Any nerve damage can be rated in addition to the arthritis, so, yes, that can be claimed separately. Make sure you have the nerve damage thoroughly examined and documented before submitting a new claim for it.

      For the range of motion, he should have recorded all the directions, but it actually doesn't make a difference in your case. Unless the spine is completely frozen or you can't bend forward more than 30 degrees, 20% is the highest rating. Measuring your other ranges would not increase your rating, thus the reason he probably didn't measure it.

  3. Sir, thank you. I have plenty of documentation for the nerve damage but nothing that says I'm unfit for duty. Maybe the PEB reviewer will take this (along with my many other ailments) into account.

    1. As long as you submit it with your other conditions, then the PEB will consider it as well. Ultimately, only the PEB makes decisions about whether or not a condition makes you Unfit for Duty.

  4. Dr. Johnson, I have been rated 20% for sciatica . It has since worsened to the point that I can hardly sit for periods longer than 6 to 10 minutes because of the pain it causes my left buttocks. can I fikle again because of the change in the condition? I have made 4 visits to the hospital this ,month alone

    1. What you need to do is call your VA and make an appointment for a C&P Exam for reevaluation of your condition. Make sure they know that the condition has worsened and you want it reevaluated for rating purposes. After the exam, you can submit to have the rating increased if the results call for an increase.

  5. I have long term effects of radiation therapy for a lymphoma I had while in service. I have CAD (with a stent in the LAD), hypertrophy, as well as stenosis in the aortic valve. I have an LVEF of 40% and am on Metoprolol, Plavix and Simvastatin indefinately. Will the CAD and valvular disease be rated seperately, pyrimided, or will they completely overlap?

    1. It will all be rated as one since they are all rated on the Heart Rating System. Basically, you'll receive a single rating for your heart, but all of your symptoms/conditions/etc will be considered when rating. You'll be given the highest rating possible based on everything that's going on, but you will only be given one rating.

    2. Thank you so much for the reply, and for all of the other great info on your site. It has made the process so much easier to navigate since finding it.

  6. I served in the army in Korea at or near the DMZ from May of 1970 until June of 1971. The time period for Agent Orange claims. I have never filed a claim but have severe heart issues ; 5 stents and subsequently quintuplets bypass surgery. I am told that this is a presumptive condition due to possible herbicide contamination. Would this qualify me for disability status? Bill McMorrow.

    1. Hi Bill -

      It most likely qualifies under the VA Presumptive List as Ischemic Heart Disease. Definitely worth submitting a VA Disability Claim:

  7. Hi Dr., I'm so confused. I have four different diagnoses on my right foot. Hallux Valus, Hallux Rigorous, hammer toes (2-5), and degenerative arthritis. My current rating is 10%. Everything that I read says each of these diagnoses is awarded 10%. Shouldn't I receive 10% for each and or 30% combined for the toes? I have an appeal hearing on March 5, 2018 and I wondering if I am barking up the right tree. Please help. Alan. You can also email me at