Citation Nr: 1307602 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 10-39 329 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an increased evaluation for endometriosis with the right ovary removed, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from September 1997 to August 2002. This matter comes before the Board of Veterans' Appeals (Board) from a July 2009 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Augusta, Maine. In August 2011, the Veteran and a witness testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran's service-connected endometriosis is evaluated as 30 percent disabling under Diagnostic Code 7629. The Veteran filed a claim for an increased rating in September 2008. In order to warrant a higher, 50 percent evaluation, the evidence would have to reflect that the Veteran had 1) lesions involving the bowel or bladder confirmed by laparoscopy, 2) pelvic pain or heavy or irregular bleeding not controlled by treatment, and 3) bowel or bladder symptoms. The Veteran asserts that she has meets all three conditions. However, the Board finds that a VA clinical opinion may be useful. Initially, the Board notes that the lesions of the bowel and bladder must be confirmed by laparoscopy. The Veteran submitted a statement dated in September 2011 in which she stated that she has "confirmed lesions involving bowel, bladder and appendix all confirmed by laparoscopy." She also submitted a statement dated in August 2010 (VA Form 9), in which she stated that she was informed by her doctor, Dr. B., that she had "implants on bladder". She further stated that she had confirmed implants on her colon. While the Veteran is competent to report what she believes she has been told by medical professionals, the Court has noted "the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995). In addition, while the Veteran is competent to report pain, she has not been shown to be competent to provide an etiology for her symptoms. This is especially true because the Veteran has been shown to have service-connected and non service-connected disabilities involving the pelvic area and bladder. The Veteran's spouse testified at the August 2011 Board hearing that the Veteran has headaches, nausea, diarrhea and painful intercourse. (The Veteran is service-connected for migraines.) July 2007 records reflect that the Veteran sought treatment for vaginal bleeding. The diagnoses were breakthrough menstruation and endometriosis. Correspondence dated in August 2007 from F. Obstetrics and Gynecology, Inc. reflects that the Veteran had sought treatment for complaints of chronic pelvic pain, severe dysmenorrhea, and abnormal uterine bleeding. A November 2007 private emergency room record reflects a diagnosis of acute pelvic inflammatory disease (PID). A March 2008 private operative report reflects that the Veteran had chronic pelvic pain and endometriosis. The record reflects that there was no evidence of endometriosis involving the intestine. There was endometriosis involving the fundus of the uterus and into the cul-de-sac. There was a peritoneal inclusion cystic lipoma type lesion in the left ovarian fossa. The cul-de-sac demonstrated a few areas of endometriosis implants. The report appears to be negative for lesions on the bowel or bladder. An August 2011 operative note reflects that the Veteran had a diagnostic laparoscopy with excision of a left fallopian tube nodule, a right ovarian remnant and infundibulopelvic ligament, and endometriosis off of the right round ligament. It also notes "lysis of adhesions between bladder and lower uterine segment." A June 2012 VA record reflects that the Veteran "comes with complaints of dysuria and pelvic pain, which is not new. Has significant history of severe endometriosis. Cystoscopy was on 1/26/2012 and showed inflammation of bladder neck and urethra, no inflammation of bladder." The diagnoses were interstitial cystitis (IC), with positive potassium sensitivity test, dysuria, and severe endometriosis with multiple laparoscopic procedures. A July 2012 VA record reflects that the Veteran reported that her menses were excruciatingly painful. A November 2012 VA record reflects that the Veteran reported that diet modifications had helped with her IC. She denied issues with incontinence of bowel or bladder in the last 12 months. She continued to have abdominal pain related to endometriosis. A December 2012 record reflects that the Veteran had had a "recent MRI" of the abdomen. The Board finds that a medical opinion with regard to the etiology of the Veteran's reported systems, and a medical opinion with regard to the locations of lesions during the pendency of the appeal, may be useful to the Board in adjudicating the Veteran's claim. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain all pertinent VA clinical records, not already associated with the claims file, for treatment from January 2012 to present, to include a 2012 MRI of the abdomen. Associate all obtained records with the claims file either electronically or in hard copy. 2. Thereafter, obtain a clinical opinion with the appropriate clinician (e.g. gynecologist or urologist) to provide an opinion as to 1) the etiology of the Veteran's bladder, bowel, and pelvic symptoms, and whether such symptoms are as likely as not due to her service-connected endometriosis or due to her non service-connected acute pelvic inflammatory disease and/or interstitial cystitis, and/or some other condition, 2) whether the Veteran has lesions involving the bowel or bladder confirmed by laparoscopy, and if so, the dates of the laparoscopy, and 3) whether it is as likely as not that the Veteran has other symptoms (e.g. nausea, painful intercourse) due to her endometriosis. The entire claims file, to include electronic records should be reviewed by the examiner, to include a November 2007 private emergency room record (diagnosis of acute PID), March 2008 private operative report, August 2011 operative note, June 2012 VA record (diagnosis of IC), and December 2012 VA records. The examiner is requested to provide a complete rationale for his or her opinion, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. 3. After undertaking any other development deemed appropriate, the RO should readjudicate the issue on appeal. If the benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and her representative with an appropriate opportunity to respond. Thereafter, the claim should be returned to the Board as warranted. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).