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.