Citation Nr: 18150739 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 12-02 768 DATE: November 15, 2018 ORDER New and material evidence having been presented, the claims of entitlement to service connection for fatigue and insomnia and for allergic rhinitis are reopened. To this limited extent only, the appeal of those issues is granted. New and material evidence not having been presented, the petition to reopen the claim of entitlement to service connection for a gynecological disability is denied. Entitlement to an evaluation in excess of 10 percent (excepting a period of temporary total disability rating from February 11, 2011, to March 31, 2011) for the service-connected residuals of excision of ganglion cysts from the left wrist and right ring finger is denied. Entitlement to an initial evaluation in excess of 10 percent for the service-connected peripheral neuropathy of the left upper extremity due to excision of ganglion cysts is denied. Entitlement to an initial compensable evaluation prior to September 12, 2011, for the service-connected hemorrhoids is denied. Entitlement to an evaluation of 10 percent, but no greater, beginning September 12, 2011, for the service-connected hemorrhoids is granted. REMANDED Entitlement to service connection for constipation is remanded. Entitlement to service connection for residuals of left ankle fracture, to include as secondary to service-connected lumbar strain and lower extremity radiculopathy, is remanded. Entitlement to service connection for fatigue and insomnia is remanded. Entitlement to a temporary total disability rating for convalescence from left ankle surgery is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for ganglion cyst of the left knee is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to an evaluation in excess of 10 percent for the period May 24, 2007, to January 24, 2016, and in excess of 40 percent beginning January 25, 2016, for the service-connected lumbosacral strain is remanded. Entitlement to an evaluation in excess of 20 percent for service-connected left and right lower extremity radiculopathy secondary to the service-connected lumbosacral strain is remanded. Entitlement to a TDIU is remanded. FINDINGS OF FACT 1. The Veteran’s first claims of service connection for fatigue and insomnia, for allergic rhinitis, and for a gynecological disability were denied in a July 1999 rating decision that was not appealed; no further evidence relevant to the Veteran’s service connection claims was submitted for a period of one year following the July 1999 rating decision. 2. Evidence relevant to the claims of service connection for fatigue and insomnia and for allergic rhinitis that was submitted since the July 1999 rating decision was not previously considered by agency decision makers; is neither cumulative nor redundant of the evidence already of record; relates to unestablished facts; and raises a reasonable possibility of substantiating the Veteran’s claims. 3. Evidence relevant to the claim of service connection for a gynecological disability that was submitted since the July 1999 rating decision was not previously considered by agency decision makers, but is cumulative and redundant of the evidence already of record and does not relate to unestablished facts. 4. Throughout the appeal period, with the exception of a period of temporary total disability rating from February 11, 2011, to March 31, 2011, the Veteran’s service-connected residuals of excision of ganglion cysts from the left wrist and right ring finger did not manifest in functional impairment or in greater than two painful scars. 5. The Veteran’s peripheral neuropathy of the left upper extremity manifested in mild symptoms including pain, numbness, weakness, and decreased sensation. 6. Prior to September 12, 2011, the service-connected hemorrhoids manifested in moderate symptoms, including occasional bleeding; thereafter, they manifested as irreducible hemorrhoids with frequent bleeding, pain, itching, and burning, but no anemia or fissures. CONCLUSIONS OF LAW 1. New and material evidence has been received since the July 1999 denial became final; the criteria for reopening the previously denied service connection claim for fatigue and insomnia have been met. 38 U.S.C. §§ 5108, 7104, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. 2. New and material evidence has been received since the July 1999 denial became final; the criteria for reopening the previously denied service connection claim for allergic rhinitis have been met. 38 U.S.C. §§ 5108, 7104, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. 3. New and material evidence has not been received since the July 1999 denial became final; the criteria for reopening the previously denied service connection claim for a gynecological disability have not been met. 38 U.S.C. §§ 5108, 7104, 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. 4. The criteria for establishing an evaluation in excess of 10 percent for service-connected residuals of excision of ganglion cysts from the left wrist and right ring finger have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.71a, 4.73, 4.118, Diagnostic Codes 5214, 5215, 5307, 7819-7804. 5. The criteria for establishing an evaluation in excess of 10 percent for service-connected peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.124a, Diagnostic Code 8715. 6. The criteria for a compensable evaluation prior to September 12, 2012, for the service-connected hemorrhoids are not met. 38 U.S.C. §§ 1155, 5107b; 38 C.F.R. §§ 3.102, 4.1-4.10, 4.114, Diagnostic Code 7336. 7. The criteria for an evaluation of 10 percent, but no greater, for the period beginning September 12, 2011, for the service-connected hemorrhoids are met. 38 U.S.C. §§ 1155, 5107b; 38 C.F.R. §§ 3.102, 4.1-4.10, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training with the United States Navy from September 1984 to December 1984 and on active duty from August 1987 to July 1997. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing in May 2015. A September 2018 rating decision granted entitlement to service connection for chronic bronchitis. This action represents a total grant of the benefit sought on appeal with respect to this issue, and it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The Board notes the Veteran has an appeal for service connection for posttraumatic stress disorder pending before the Board. On her October 2016 substantive appeal form relevant to this issue, the Veteran requested a hearing, which has not yet been scheduled. Accordingly, this issue will be addressed in a separate decision once the hearing is held. A February 2018 rating decision granted service connection for peripheral neuropathy of the left upper extremity associated with the excision of ganglion cysts of the left wrist, and assigned a 10 percent rating, effective January 5, 2015. The grant of separate service connection and rating for the peripheral neuropathy stems from the claim for an increased rating for residuals of excision of ganglion cysts on the left wrist. As such, it is part and parcel of the appeal for a higher rating for the left wrist ganglion cysts disability. As such, the rating assigned for peripheral neuropathy is also for consideration by the Board at this time. See AB v. Brown, 6 Vet. App. 35 (1993). Finally, the Board notes that the Veteran filed for service connection for several claims as due to an undiagnosed illness. However, the record does not indicate that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(e). Accordingly, the Board has not considered the presumptions available to servicemembers with qualifying service under section 3.317, but instead has considered the Veteran’s service connection claims on all theories of causation applicable to each claim, including direct and secondary service connection. New and Material Evidence A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision, or new and material evidence is received during the appeal period after the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). The threshold is low and does not require new and material evidence regarding each element of the claim that had not been proved in the prior final decision. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New evidence is defined as existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). 1. Whether new and material evidence has been received to reopen the claim of service connection for fatigue and insomnia The Veteran filed her initial claims for service connection for fatigue and insomnia in August 1997. The RO denied service connection for these, treating them as one related claim, in a July 1999 rating decision based on a finding that there was no evidence of a disability warranting a compensable evaluation. The Veteran was notified of that decision in an August 1999 notice letter. The Veteran did not submit a notice of disagreement with the decision within one year of that notice letter, nor did she submit any additional evidence respecting the claim until she filed her petition to reopen her service connection claim in May 2007. As no timely notice of disagreement or new and material evidence was received during the appeal period following the August 1999 notice letter, the July 1999 rating decision became final. See 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.1103; Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). New and material evidence is therefore required to reopen the claim of service connection for fatigue and insomnia. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156; Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Since the July 1999 rating decision, evidence of a current disability relating to disrupted sleep has been associated with the record, and the Veteran testified at a Board hearing in May 2015 regarding her symptoms. Therefore, the Board finds that new and material evidence which tends to substantiate the Veteran’s claim of service connection for fatigue and insomnia has been received in her case, and the claim is reopened. See 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110, 117 (2010) (medical evidence indicating a medical opinion is warranted is sufficient to reopen a claim). 2. Whether new and material evidence has been received to reopen the claim of service connection for allergic rhinitis The Veteran filed her initial claim for service connection for a severe sinus condition in August 1997. The RO denied service connection for that claim in a July 1999 rating decision based on a finding that there was no evidence of a chronic condition with onset in service. The Veteran was notified of that decision in an August 1999 notice letter. The Veteran did not submit a notice of disagreement with the decision or any additional evidence respecting the claim within one year of that notice letter. As no timely notice of disagreement or new and material evidence was received during the appeal period following the July 1999 notice letter, the July 1999 rating decision became final. See 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.1103; Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). New and material evidence is therefore required to reopen the claim of service connection for allergic rhinitis. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156; Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Since the July 1999 rating decision, the Veteran testified at the May 2015 Board hearing that she was treated by VA doctors for allergies and used over-the-counter medications as well since service. She also testified that she had a productive cough and occasionally lost her voice due to the allergic rhinitis. Therefore, the Board finds that new and material evidence which tends to substantiate the Veteran’s claim of service connection for allergic rhinitis has been received in this case, and the claim is reopened. See 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110, 117 (2010) (medical evidence indicating a medical opinion is warranted is sufficient to reopen a claim). 3. Whether new and material evidence has been received to reopen the claim of service connection for a gynecological disability The Veteran filed her initial claim for service connection for female medical problems in August 1997. The RO denied service connection for that claim in a July 1999 rating decision based on a finding that the complained-of conditions were either congenital defects or not considered disabilities for compensation purposes. The Veteran was notified of that decision in an August 1999 notice letter. The Veteran did not submit a notice of disagreement with the decision within one year of that notice letter, nor did she submit any additional evidence respecting the claim until she filed her petition to reopen service connection in May 2007. As no timely notice of disagreement or new and material evidence was received during the appeal period following the August 1999 notice letter, the July 1999 rating decision became final. See 38 C.F.R. §§ 3.156(b), 20.200, 20.201, 20.1103; Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). New and material evidence is therefore required to reopen the claim of service connection for a gynecological disability. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156; Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Since the July 1999 rating decision, VA treatment records have been associated with the record and are the only new evidence related to this claim. These records are silent as to treatment and other gynecological care, except for complaints of one 7-day episode of post-menopausal bleeding in August 2016. A follow-up ultrasound showed some benign, fluid-filled cysts but was otherwise unremarkable. No diagnosis was made, and the Veteran was not prescribed any follow-up treatment. At the May 2015 Board hearing, the Veteran did testify about her gynecological disability claim, but did not describe the current symptoms or report any ongoing symptomatology since service, noting only the “irregular menstrual cycle” that was found to be a congenital defect and “problems” after the birth and subsequent death of her son in 1988. In fact, she did not describe the claim any differently than it was presented at the time of the July 1999 rating decision, and did not contribute any new information about the claim. As the only new evidence associated with the record does not speak to any of the elements of service connection, the Board finds that it is not material to the Veteran’s claim. The petition to reopen the claim for service connection for a gynecological disability is therefore denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant’s ordinary activity. 38 C.F.R. § 4.10; see generally Schafarth v. Derwinski, 1 Vet. App. 589 (1991). 4. Entitlement to an evaluation in excess of 10 percent (excepting a period of temporary total disability rating from February 11, 2011, to March 31, 2011) for the service-connected residuals of excision of ganglion cysts from the left wrist and right ring finger The Veteran’s residuals of the excision of ganglion cysts from the left wrist and right ring finger is currently rated as 10 percent disabling under Diagnostic Code (DC) 7819-7804. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code here indicates that the Veteran is service connected for benign neoplasms of the skin (DC 7819), which are rated using criteria related to scarring (DCs 7800-7805) or impairment of function. Diagnostic Code 7804 governs painful scars. Under this code, a 10 percent evaluation is assigned for 1 or 2 unstable or painful scars; a 20 percent evaluation is assigned for 3 or 4 unstable or painful scars; and, a 30 percent evaluation is assigned for 5 or more unstable or painful scars. 38 C.F.R. § 4.118, DC 7804. Note 1 indicates that an unstable scar is one where, for any reason, there is frequent loss of covering over the scar. Additionally, if one or more scars are both unstable and painful, an extra 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. Id., Note 2. Diagnostic Code 7800 governs scars of the head, face, or neck, and thus is not relevant in this case. Similarly, DCs 7801 and 7802 pertain to nonlinear scars, either deep or superficial, and thus are not relevant in this case. Lastly, DC 7805 directs the evaluator to rate other scars and their effects under an appropriate diagnostic code, which in this case is DC 7804. The record reflects the Veteran has two scars related to the service-connected ganglion cysts. One scar is located on the Veteran’s left wrist; a July 2008 VA examination noted previous aspiration of the cyst on the left wrist, but the cyst recurred. The Veteran reported at this examination that the cyst was painful, and the examiner noted that the cyst was tender to palpation and had an elevated surface. The Board notes that, in February 2011, the cyst was excised from the left wrist. On a January 2018 VA examination, the examiner described the resulting scarring as linear and approximately 2 centimeters in length. The examiner did not note that that the left wrist scar was painful. The other scar is located on the Veteran’s right ring finger. On the July 2008 VA examination, it was described as measuring approximately 1 centimeter by 0.5 centimeter. There was no tenderness, instability, tissue loss, or abnormal pigmentation or texture. On the January 2018 examination, the right ring finger scar was described as linear and approximately 1.25 centimeters in length. The examiner did not note that that the ring finger scar was painful. At the January 2018 VA examination, the Veteran also underwent testing for functional impairment of her wrist. The left wrist showed full range of motion, there were no flare-ups reported, there was no objective evidence of pain noted on weight-bearing or range of motion testing, and there was no weakness, fatigability, or coordination noted on repetitive use. The examiner did note slight reduction in muscle strength on extension of the left hand. The Veteran testified at the May 2015 Board hearing that she experiences a pins and needles feeling in her left hand since the February 2011 procedure to excise the ganglion cyst from her left wrist. The Veteran has been assigned a separate rating for peripheral neuropathy to compensate for these symptoms – that rating is addressed below. An increase in the evaluation of the residuals and scarring for neurological symptoms would constitute impermissible pyramiding; a veteran may not be compensated twice for the same symptomatology. See 38 C.F.R. § 4.14. The Veteran did not describe any further symptoms of the excision or the cysts to her left wrist and right ring finger. Aside from the procedure to excise the cyst from the Veteran’s left wrist, her VA treatment records do not contain treatment for or complaints about residuals of the left wrist and right ring finger ganglion cysts that is not neurological in nature. As the evidence does not indicate the presence of 3 or more scars that are unstable or painful, an evaluation in excess of 10 percent under DC 7804 is not appropriate in this case. The Board has also considered, as directed by DC 7819, an evaluation based on impairment of function. However, the only impairment noted in the record that is not neurological in nature is a slight reduction in strength on extension of the left wrist. The Veteran has a full range of motion in her left wrist, full strength in flexion, and otherwise no functional impairment in her left wrist. As such, an evaluation under the limitation of motion or muscular injuries criteria is not appropriate. Accordingly, an evaluation in excess of 10 percent for the service-connected residuals of excision of ganglion cysts from the left wrist and right ring finger is not warranted. 5. Entitlement to an evaluation in excess of 10 percent for peripheral neuropathy of the left upper extremity due to excision of ganglion cysts The Veteran’s left upper extremity peripheral neuropathy has been rated using Diagnostic Code 8715 for neuralgia, which provides the rating criteria for paralysis of the median nerve. 38 C.F.R. § 4.124a. The evidence of record indicates the Veteran’s dominant hand is her right hand, so the minor ratings apply to the upper left extremity neuropathy. Diagnostic Code 8715 provides that 10, 20, and 40 percent ratings are assigned to a non-dominant extremity depending on whether the incomplete paralysis of the extremity is mild, moderate, or severe, respectively. Complete paralysis of the extremity warrants a 60 percent rating. 38 C.F.R. § 4.124a, DC 8715. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Neuralgia, characterized usually by a dull and intermittent pain, has a maximum evaluation equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The words “mild,” “moderate,” and “severe,” as used in the various diagnostic codes, are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. At the May 2015 Board hearing, the Veteran described numbness and a pins and needles feeling in her left hand, which made it difficult to pick up objects and feel what she is doing with her left hand. Her VA treatment records also reflect complaints of pain, numbness, and weakness in her left hand. In January 2018, the Veteran was afforded a VA peripheral nerves examination, at which she reported the neurological symptoms had remained the same in severity since their onset after the surgery to excise the ganglion cyst from her left wrist. The examiner noted mild constant pain, paresthesias, and numbness in the Veteran’s left upper extremity, and slightly reduced muscle strength in the left elbow flexion, elbow extension, wrist extension, hand grip, and thumb to index finger pinch. The examiner also noted decreased sensation in the left hand and fingers. There was no muscle atrophy noted, and reflexes were all normal. The examiner concluded that these results indicated mild incomplete paralysis of the Veteran’s median nerve. The Board finds that a 10 percent evaluation, and no greater, for the left upper extremity peripheral neuropathy is appropriate. The Veteran’s VA treatment records contain complaints of numbness, pain, and weakness in her left hand, but the symptoms as reported by the Veteran have not triggered any treatment for the condition. Further, the January 2018 VA examination indicates a mild level of symptoms; the Veteran’s muscle strength is slightly affected but there is no atrophy and her reflexes remain normal. Decreased sensation, mild pain, mild paresthesias, and mild numbness, taken together, best describe a 10 percent evaluation for the peripheral neuropathy of the left upper extremity. 6. Entitlement to an initial compensable evaluation prior to December 1, 2011, and in excess of 10 percent thereafter for service-connected hemorrhoids The Veteran’s service-connected hemorrhoid disability is currently evaluated under DC 7336 as noncompensable prior to December 1, 2011, and as 10 percent disabling thereafter. The Veteran submitted a written statement on December 1, 2011, requesting an increase in her evaluation because her physician had found 10 internal and external hemorrhoids and had recommended surgery to remove the hemorrhoids. Diagnostic Code 7336 provides the rating criteria for external or internal hemorrhoids. Hemorrhoids that are mild or moderate are assigned a noncompensable rating. Hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are assigned a 10 percent rating. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are assigned a 20 percent rating. 38 C.F.R. § 4.114. In November 2010, the Veteran was afforded a VA examination, at which the examiner identified 5 external hemorrhoids less than 1 centimeter each. The examiner did not find evidence of thrombosis, bleeding, fissures, or excessive redundant tissue. The Veteran reported bright red bleeding from the hemorrhoids at times, as well as constipation. In September 2011, the Veteran reported to her primary care physician that her hemorrhoids had been bleeding off and on since April 2011. She also reported the symptoms were exacerbated by alternating diarrhea and constipation, and she reported one episode of coffee ground stool. She stated that the symptoms and discomfort made it difficult to sit long enough to perform her job duties. In November 2011, the Veteran underwent a routine colonoscopy based on a family history of colon cancer. When discussing the results with her physician later in November 2011, the Veteran reported that she had been experiencing bleeding from her hemorrhoids prior to the colonoscopy, and that it had worsened since the colonoscopy. The physician recommended a surgical consultation for evaluation for a hemorrhoidectomy. In March 2012, the Veteran attended the surgical consultation, and reported that her symptoms had worsened in the past six months. She reported bleeding, alternating constipation and diarrhea, burning, itching, pain, and some fecal incontinence. Also in March 2012, the Veteran attended an VA examination, at which the Veteran reported pain and frequent bleeding. The examiner noted large or thrombotic hemorrhoids that were difficult to reduce. Anemia and fissures were not noted. Based on this evidence, the Board finds that a 10 percent evaluation for the service-connected hemorrhoids is appropriate beginning September 12, 2011, the date the Veteran reported an increase in hemorrhoid symptoms to her primary care physician. Prior to this date, the evidence of record indicates moderate hemorrhoid symptoms, including the presence of 5 hemorrhoids measuring less than 1 centimeter each. The Veteran reported occasional bleeding at the November 2010 VA examination. On September 12, 2011, the Veteran reported worsening hemorrhoid symptoms, including more frequent bleeding and increased discomfort while sitting. The March 2012 VA examination identified large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, and around this time, the Veteran reported burning, itching, pain, and some fecal incontinence as well as increased bleeding. These symptoms coincide with the criteria describing a 10 percent evaluation for hemorrhoids. As there is no evidence of persistent bleeding with secondary anemia or with fissures, a 20 percent evaluation is not appropriate. Therefore, the Board finds that a noncompensable evaluation is warranted for the period prior to September 12, 2011, and a 10 percent evaluation, and no greater, is appropriate thereafter. REASONS FOR REMAND 1. Entitlement to service connection for constipation The Veteran testified at the May 2015 Board hearing that her doctors informed her that a known side effect of several medications she takes for service-connected conditions is constipation. The Veteran was afforded a VA examination in January 2018 relevant to this claim, but the examiner did not address this contention or consider the Veteran’s medication regime at all in the examination report. The examination is therefore inadequate to decide this claim, and a new opinion must be obtained on remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). 2. Entitlement to service connection for residuals of left ankle fracture, to include as secondary to service-connected lumbar strain and lower extremity radiculopathy, is remanded. The Veteran was afforded a VA ankle examination in June 2014, at which the examiner opined that the Veteran’s ankle injury was not related to her service-connected lumbar strain. However, the Veteran has consistently contended that she injured her ankle in a fall due to numbness in her legs, and as of the June 2014 examination, she was not service-connected for lower extremity radiculopathy. Since that time, service connection has been granted for lower extremity radiculopathy; thus, a new opinion is necessary addressing whether the ankle injury was caused by the lower extremity radiculopathy. 3. Entitlement to a temporary total disability rating for convalescence from left ankle surgery is remanded. The temporary total disability issue is intertwined with the left ankle issue, as it depends on a grant of that issue, and therefore is also remanded at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 4. Entitlement to service connection for fatigue and insomnia is remanded. The Veteran underwent a sleep study in March 2015 at a VA medical facility for complaints of snoring and awaking fatigued. She was subsequently diagnosed with obstructive sleep apnea and prescribed a CPAP machine for treatment. A medical opinion is necessary to determine whether the Veteran’s complaints of fatigue and insomnia are symptoms of obstructive sleep apnea or an independent disability, and whether fatigue and insomnia are related to service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 5. Entitlement to service connection for a cervical spine disability is remanded. The Veteran was afforded a VA cervical spine examination in January 2018, at which the examiner diagnosed a cervical strain. However, in formulating an opinion about whether the cervical strain was related to service, the examiner failed to consider the Veteran’s lay statements and those of her family and colleagues present in the record, reporting neck pain continuously since the motor vehicle accident in service. The examiner only noted the Veteran did not report neck pain on her separation examination and that there was no medical documentation of care for neck pain during or after service. In other words, the examiner appears to have impermissibly dismissed the Veteran’s otherwise competent and credible reports of neck pain solely because these complaints were not documented in treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). On remand, the RO should obtain a new opinion addressing all evidence relevant to the Veteran’s claim for service connection for a cervical spine disability, including the report of shoulder pain noted on the Veteran’s discharge examination and subsequent shoulder instability. 6. Entitlement to service connection for ganglion cyst on the left knee is remanded. Similarly, at the January 2018 VA examination, the Veteran reported that she first started developing the ganglion cyst on her left knee in the 1990s. However, the examiner opined that the cyst is less likely than not incurred in or caused by service, noting that there was nothing relevant to this issue in the service treatment records or in VA treatment records until well after service. Again, the examiner failed to address the Veteran’s lay statements regarding the onset of the ganglion cyst on the left knee, and so the opinion is inadequate for decision-making purposes. See Dalton, 21 Vet. App. at 39-40; see also Buchanan, 451 F.3d at 1337. On remand, the RO should obtain a new opinion addressing all evidence relevant to the Veteran’s claim for service connection for a ganglion cyst on the left knee. 7. Entitlement to service connection for allergic rhinitis is remanded. The opinion in the January 2018 VA examination is also inadequate to make a determination on the issue of service connection for allergic rhinitis. The Veteran testified at the May 2015 Board hearing that she reported similar symptoms during service, including sinus tenderness, nasal congestion, and sore throat; the Veteran further asserted that the current allergic rhinitis disability might be related to her conceded in-service asbestos exposure. The examiner, in proffering an opinion, noted only that there was no link noted in the Veteran’s service treatment records; the examiner did not offer an explanation, for example, as to why any of the assertions the Veteran made do not constitute a link between her current disability and her service, and so the opinion is inadequate for decision-making purposes. See Dalton, 21 Vet. App. at 39-40; see also Buchanan, 451 F.3d at 1337. Accordingly, a new opinion is necessary to properly address all evidence relevant to the Veteran’s claim for service connection for allergic rhinitis. 8. Entitlement to an evaluation in excess of 10 percent for the period from May 24, 2007, to January 24, 2016, and in excess of 40 percent thereafter for the service-connected lumbosacral strain is remanded. The Veteran testified at the May 2015 Board hearing that she underwent treatment with a physical therapist for a period of time after the November 2013 fall, but the record only contains the initial plan of treatment from this physical therapist. As this initial record does contain range of motion measurements, and indicates improving the range of motion as a goal of the treatment, it appears the complete set of records would contribute to an accurate picture of the Veteran’s lumbar spine disability during this time period. On remand, the RO should attempt to obtain these private records. The Board notes that the range of motion measurements in the physical therapy record were taken using an inclinometer. A goniometer is required for VA examinations, see 38 C.F.R. § 4.46, but the results in the private physical therapy record cannot be used to evaluate the Veteran’s disability with VA rating criteria, as the tool used indicates a different range of motion than that described in the rating schedule. On remand, after making appropriate attempts to obtain the full set of physical therapy records, the RO should obtain an opinion estimating the range of motion measurements taken in the private records in terms of the range of motion used by VA in evaluating spine disabilities. 9. Entitlement to an evaluation in excess of 20 percent for service-connected left and right lower extremity radiculopathy secondary to the service-connected lumbosacral strain is remanded. The issues of an increased evaluation of radiculopathy of the left and right lower extremity are raised as part of the claim for an increased evaluation of the lumbosacral strain. These issues are intertwined with the above remanded issues and are also remanded at this time. See Henderson, 12 Vet. App. at 20; Harris, 1 Vet. App. at 183. 10. Entitlement to a TDIU is remanded. The TDIU issue is intertwined with the above remanded issues and is also remanded at this time. See Henderson, 12 Vet. App. at 20; Harris, 1 Vet. App. at 183. The matters are REMANDED for the following action: 1. Ask the Veteran to identify any private treatment that she may have had for her lumbar spine disability that is not already of record, including any records from her physical therapy treatment after the November 2013 fall. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that she can make an attempt to obtain those records on her own behalf. 2. Forward the claims file to an appropriate clinician to determine whether the reported constipation is related to the Veteran’s military service. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the constipation is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected disabilities, including medications used to treat these disabilities. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the constipation prior to aggravation by the service-connected disabilities. Please note, causation and aggravation are separate concepts and must be addressed independently. The examiner should address the Veteran’s lay statements regarding continuity of symptomatology since onset and/or since discharge from service. The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 3. Forward the claims file to an appropriate clinician to determine whether the left ankle disability is related to the Veteran’s military service. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the left ankle disability is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected lumbar disability or any other service-connected disabilities. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the left ankle disability prior to aggravation by any service-connected disability. Please note, causation and aggravation are separate concepts and must be addressed independently. The examiner should specifically address the Veteran’s lay statements regarding the November 2013 fall, as well as the emergency department records from that injury. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Schedule the Veteran for an examination with an appropriate clinician to determine whether any sleep disorder manifesting in fatigue and/or insomnia is related to the Veteran’s military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all sleep disorders currently found. For each sleep disorder identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should address the Veteran’s lay statements regarding continuity of symptomatology since onset and/or since discharge from service. The examiner should address any other pertinent evidence of record, including the March 2015 VA treatment record detailing the Veteran’s sleep study. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 5. Schedule the Veteran for an examination with an appropriate clinician to determine whether the diagnosis of any neck or shoulder disability is related to the Veteran’s military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all neck and shoulder disabilities currently found. For each disability identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. If no neck disability is found, the examiner should address whether the complaints in the record of neck pain are a manifestation of any shoulder disability. In formulating the requested opinions, the examiner should address the Veteran’s lay statements regarding continuity of symptomatology since onset and/or since discharge from service. The examiner should address any other pertinent evidence of record, including the May 2015 written statement from the Veteran’s colleague and the Veteran’s Board hearing testimony. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 6. Forward the claims file to an appropriate clinician to determine whether the ganglion cyst near the Veteran’s left knee is related to the Veteran’s military service. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should specifically address the Veteran’s lay statements regarding when the cyst began forming and when it became symptomatic. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 7. Forward the claims file to an appropriate clinician to determine whether the allergic rhinitis diagnosis is related to the Veteran’s military service. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran’s active service. The examiner should also address the Veteran’s contention that the current allergic rhinitis might be related to her conceded in-service exposure to asbestos. The examiner should specifically address the Veteran’s lay statements regarding the onset of her current symptoms. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 8. Forward the claims file to an appropriate clinician to comment upon the lumbar spine range of motion measurements in the Veteran’s private treatment records taken by inclinometer and whether these measurements can be described in terms responsive to VA rating criteria which require use of a goniometer in measuring range of motion. If such an estimation cannot be made without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Josey, Associate Counsel