Citation Nr: 1316932 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 06-25 008A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to a disability evaluation greater than 30 percent for service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran had active service from August 1973 to August 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. 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 contends his rectal disability is sufficiently severe to warrant the assignment of a rating in excess of 30 percent. In July 2010, the Board remanded this case because report of VA examination dated in August 2006 failed to distinguish those symptoms attributable to the Veteran's service-connected disability from his non-service connected gastrointestinal disorders. The record shows that the Veteran has been diagnosed with multiple disabilities affecting the gastrointestinal tract/rectum, including hemorrhoids, irritable bowel syndrome (IBS), and diverticulosis. Pursuant to Board remand, a VA examination for the rectum and anus was conducted in September 2010. The report of examination reflects a medical history, review of the claims file, and physical exam findings. Physical exam showed normal appearing anus with very slight amount of fecal stand, a tight rectal sphincter, no pain with digital rectal exam, and slight suprapubic tenderness. The impression was IBS and very mild fecal incontinence. The examiner opined that these conditions "are not as likely as not caused by or the result of previous fistulectomy, sphincterotomy or cryptotomy that was performed while in the service." A supplemental medical opinion by a physician's assistant, not the original examiner, opined that: The fistula was most likely related to an abscess and was treated with surgery in 1977 and resolved. The fissure that occurred post military in 1986 is a common and usually is a result of of [sic] trauma to the anus such [as] passing hard stool. He received surgical treatment for fissure. Diverticulosis is a disease of the large bowel which is due to pouches forming due to weakening of the bowel wall. IBS is a disease that caused chronic diarrhea without organic finding. The fistula in 1977 and other complaints are separate evnets [sic] and not related. Having reviewed the report of VA examination along with the supplemental opinion, the Board finds that the medical information given is not responsive to the Board's July 2010 remand instructions. In particular, there is very little information or discussion as to whether there are any symptoms present that are attributable to the Veteran's service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano versus his nonservice-connected gastrointestinal disorders. Also, to the extent that the report of examination and the supplemental opinion address whether IBS and diverticulosis are not related to service or service connected rectum/anus disorder, the medical opinion is inadequate because neither the original examiner nor the physicians assistant supported his conclusions with an analysis the Board may consider and weigh the other evidence record. It is noted that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Such is not the case here. Therefore, remand for another VA examination and medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders). Accordingly, the case is REMANDED for the following action: 1. The RO or AMC should obtain all updated VA treatment records and any other outstanding records pertinent to the Veteran's claim. 2. The RO or AMC should schedule the Veteran for a VA rectum/anus examination by a physician to ascertain the severity of all symptoms and manifestation associated with service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano. The examiner should: * Identify all gastrointestinal and rectal/anus symptoms reported by the Veteran. It is noted that the Veteran's report of symptoms, to include frequency and severity, should be accepted as truthful unless otherwise indicated by examination or the record. * Indicate for each symptom whether it is as likely as not associated with service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano. * Indicate whether the Veteran has occasional involuntary bowel movements, necessitating wear of pad; and, if so, the cause of this (i.e. service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano). * Indicate whether the Veteran has extensive leakage and daily frequent involuntary bowel movements; and, if so, the cause of this (i.e. service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano). Also, the VA physician should provide a medial opinion on whether any currently found disorder(s) (including IBS and diverticulosis) of the gastrointestinal tract is proximately due to or aggravated by service-connected fistulectomy, sphincterotomy, cryptotomy for recurrent fistula in ano or hemorrhoidectomy. The claims file along with any pertinent medical records located in the Veteran's Virtual VA file not in the claims file must be reviewed. A complete rationale for all opinions must be provided. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., that he or she relied upon in reaching his or her conclusion(s). If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss why an opinion is not possible. 3. Then, the RO should also undertake any other development it determines to be warranted. 4. After the development requested above has been completed to the extent possible, the RO or AMC should readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the claims files are returned to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ MICHAEL LANE 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).