Citation Nr: 21002560 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 10-31 986A DATE: January 14, 2021 REMANDED Entitlement to an initial rating in excess of 60 percent for Reiter’s syndrome prior to September 27, 2019, to include iritis, prostatitis, irritable bowel syndrome (IBS), and degenerative joint disease of the knees, ankles, feet, and hands. REASONS FOR REMAND The Veteran served on active duty from January 1986 to December 1989, November 1991 to May 1992, July 1993 to April 1998, and November 1998 to December 2008. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the case for further development in April 2014, September 2016, October 2017, and February 2019. The case has since been returned to the Board for appellate review. In an August 2020 rating decision, the RO assigned a 100 percent rating for the service-connected Reiter’s syndrome effective from September 27, 2019. Nevertheless, the issue remains in appellate status, as the maximum schedular rating has not been assigned for the period prior to September 27, 2019. AB v. Brown, 6 Vet. App. 35, 38 (1993). Upon review of the record, the Board finds that the claim must be remanded. The Board sincerely regrets the additional delay caused by this remand but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claim. The Veteran’s service-connected Reiter’s syndrome is currently assigned a 60 percent evaluation prior to September 27, 2019, and a 100 percent rating thereafter. His disability is rated by analogy under 38 C.F.R. § 4.71a, Diagnostic Code 5002 for rheumatoid arthritis. Under Diagnostic Code 5002, a claimant is awarded the higher of two evaluations, evaluated either (1) as an active process or (2) based on the chronic residuals associated with the disease such as limitation of motion or ankylosis. For active process, a 100 percent rating is assigned for constitutional manifestations associated with active joint involvement which are totally incapacitating. A 60 percent rating is assigned for less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times per year or a lesser number over prolonged periods. 38 C.F.R. § 4.71a, Diagnostic Code 5002. For chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, the disability is rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5002. A Note to Diagnostic Code 5002 also instructs that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. Id. Initially, the Board notes that numerous residuals have been attributed to the Veteran’s Reiter’s syndrome. The record clearly reflects that several non-orthopedic disorders have been rated as residuals of the Veteran’s service-connected Reiter’s syndrome including iritis, prostatitis, and IBS. See March 2009 and June 2010 rating decisions. The record also shows that orthopedic disorders have been rated as residuals of the disability, including the ankles, feet, knees, and hands. See March 2009 and June 2010 rating decisions. The evidence of record also documents complaints related to the Veteran’s cervical spine, hips/sacroiliac joints, elbows, wrists, and skin. With respect to the cervical spine, a June 2014 VA cervical spine examination report noted a diagnosis of Reiter’s syndrome (reactive arthritis). In a September 2014 rating decision and August 2018 Supplemental Statement of the Case (SSOC), the RO considered findings pertaining to the cervical spine. The September 2016 and October 2017 Board remands also stated that chronic residuals of the Veteran’s Reiter’s syndrome noted during the appeal period included cervical spine symptoms. With respect to the sacroiliac joints, in September 2016 and October 2017, the Board remanded the case, in part, to obtain VA examinations to address any hip/sacroiliac joint symptoms. The AOJ also considered VA examination findings pertaining to the Veteran’s hips in an August 2018 SSOC. With respect to the skin, in October 2017, the Board directed the examiner to describe all symptomatology associated with the Veteran’s Reiter’s syndrome, including any skin rashes. The RO also considered examination findings pertaining to the Veteran’s skin in the August 2018 SSOC. With respect to the bilateral elbows and wrists, the RO denied service connection for Reiter’s syndrome and arthritis of the bilateral wrists and elbows in a March 2009 rating decision. In June 2009, the Veteran submitted a notice of disagreement (NOD) with respect to the initial ratings assigned for IBS and degenerative joint disease of the bilateral knees and ankles associated with his Reiter’s syndrome. The RO issued a statement of the case (SOC) in July 2010. In so doing, the RO addressed the issues of entitlement to an increased evaluation for the service-connected residuals of Reiter’s syndrome, as well as entitlement to service connection for Reiter’s syndrome and arthritis of the bilateral elbows and wrists. The RO also notified the Veteran that his appeals pertaining to the elbows and wrists were reactivated when it accepted an August 2010 correspondence as a substantive appeal. Moreover, the Veteran was afforded VA examinations in connection with his residuals of Reiter’s syndrome in September 2019 during which the examiner noted diagnoses of Reiter’s syndrome with chronic bilateral residual wrist and elbow pain. The Board notes that the Veteran’s appeal stems from the initial rating assigned for his service-connected Reiter’s syndrome. Moreover, the record reflects that both the RO and the Board have considered various residuals of Reiter’s syndrome throughout the appeal period. As the Veteran’s service-connected Reiter’s syndrome has been noted to involve multiple joints, the Board will consider any residuals of the wrists, elbows, hips/sacroiliac joints, and cervical spine that have been attributed to Reiter’s syndrome as part of the increased rating issue on appeal. Moreover, as the Board and the RO initially considered symptoms pertaining to the skin as part of the increased rating issue on appeal, the Board will address any skin residuals attributable to Reiter’s syndrome. The VA examinations prior to September 2019 indicate that the Veteran’s Reiter’s syndrome did not include constitutional manifestations associated with active joint involvement that were totally incapacitating. See October 2008, June 2014, January 2017, and March 2018 VA examination reports. The VA examinations throughout the appeal also note that the Veteran’s Reiter’s syndrome required continuous medication for control. However, the examination reports do not address the nature of the Veteran’s exacerbations without the effects of medication. In addition, in a September 2019 VA non-degenerative arthritis examination report, the examiner indicated that the Veteran had constitutional manifestations, but he did not identify any specific manifestations. Therefore, the Board finds that a remand is necessary to obtain a VA medical opinion to ascertain whether the Veteran’s Reiter’s syndrome was productive of constitutional manifestations associated with active joint involvement that were totally incapacitating without the use of medication prior to September 27, 2019. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Board notes that the evidence of record also suggests that the Veteran’s chronic residuals of Reiter’s syndrome includes back and shoulder symptoms. The Veteran is separately service-connected for right and left shoulder tendonitis and degenerative joint disease of the lumbar spine. In a March 2018 VA medical opinion, the examiner indicated that the Veteran’s Reiter’s syndrome included shoulder residuals. In December 2019 VA examination reports, the examiner diagnosed the Veteran with bilateral shoulder and spine degenerative arthritis. He also diagnosed the Veteran with Reiter’s syndrome chronic residuals. In a December 2019 VA medical opinion, the examiner stated that he did not feel the Veteran’s reactive arthritis could be blamed for the destruction noted on imaging studies. Rather, he opined that the imaging findings may represent a mixed process of degenerative and reactive arthritis. In rendering his opinion, the examiner referenced imaging findings for the lumbar spine, thoracic spine, cervical spine, hips, and shoulders. As noted above, the Veteran is separately service-connected for lumbar spine and shoulder disabilities. However, the examination findings of record do not address whether it is possible to distinguish between the symptoms attributable to the Veteran’s service-connected Reiter’s syndrome from the symptoms caused by other service-connected disabilities or nonservice-connected disorders. As discussed above, under Diagnostic Code 5002, a claimant is assigned the higher evaluation for active process or chronic residuals associated with the disease. The Board notes that the October 2008, June 2014, January 2017, and September 2019 VA examination findings for the joints currently attributed to the Veteran’s Reiter’s syndrome do not fully comply with Correia v. McDonald, 28 Vet. App. 156 (2016). In this regard, the October 2008 VA examinations did not include passive range of motion testing for the bilateral ankles, elbows, knees, and wrists. The October 2008 VA hand examination also did not include range of motion testing on weight-bearing and nonweight-bearing for the hands or fingers. The June 2014 VA examinations did not include range of motion testing on passive range of motion, weightbearing, and nonweight-bearing for the knees or cervical-spine. The January 2017 VA examinations did not include range of motion testing on passive range of motion and nonweight-bearing for the knees or the cervical-spine. Finally, the September 2019 VA examination reports for the cervical spine and hips did not provide estimates in the form of degrees of motion lost due to pain on passive motion and nonweight-bearing. In addition, the June 2014, January 2017 and March 2018 VA examinations did not adequately address the Veteran’s reported flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26, 34 (2018). In this regard, the June 2014 VA examiner did not estimate range of motion lost during flare-ups for the cervical spine. The January 2017 VA examiner did not indicate whether he could estimate range of motion lost during a flare-ups based on information gleaned from the medical evidence of record for the Veteran’s ankles, hands, or knees. In addition, the January 2017 examiner did not address the frequency, duration, characteristics, severity, and functional loss due to flare-ups for the cervical spine. The March 2018 VA examiner stated that it was not possible to estimate loss of motion during flare-ups without resorting to speculation for the Veteran’s hands and knees. However, he did not indicate whether any efforts were made to glean information from the Veteran or the medical evidence of record. The Board is not permitted to base its decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, a retrospective medical opinion is needed to evaluate the Veteran’s Reiter’s syndrome under the relevant criteria for the period prior to September 27, 2019. See Chotta v. Peake, 22 Vet. App. 80 (2008). In the September 2016 remand, the Board also directed the AOJ to consider whether separate evaluations were warranted for the Veteran’s residuals of iritis, prostatitis, and IBS. On remand, the AOJ should consider whether any separate ratings are warranted for his non-orthopedic chronic residuals of Reiter’s syndrome. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Obtain a retrospective medical opinion from an appropriate examiner regarding the nature and severity of the Veteran’s service-connected residuals of Reiter’s syndrome during the period on appeal from January 1, 2009 to September 26, 2019. The entire claims file should be made available to and be reviewed by the clinician. To the extent possible, the examiner should provide opinions responding to the following: (a) The examiner should report all signs and symptoms necessary for rating the Veteran’s service-connected Reiter’s syndrome for the period prior to September 27, 2019. He or she should evaluate the Veteran’s Reiter’s syndrome as both an active process and as productive of chronic residuals. In so doing, the examiner should consider the non-orthopedic chronic residuals of Reiter’s syndrome noted in the record, including eye conditions, prostatitis, irritable bowel syndrome, and skin conditions. He or she should also consider the chronic joint residuals of Reiter’s syndrome noted in the record, including residuals in the ankles, cervical spine, elbows, wrists, hands/fingers, sacroiliac joints, knees, ankles, and feet. (b) The examiner should state the total number of incapacitating exacerbations occurring per year and the symptoms associated with those exacerbations. He or she should state whether the Veteran would experience constitutional manifestations associated with active joint involvement that is totally incapacitating without the ameliorating effects of medication. To the extent possible, the examiner should clarify the constitutional manifestations of the Veteran’s Reiter’s syndrome that were identified during the September 2019 VA non-degenerative arthritis examination. (c) The examiner should state whether the Veteran’s Reiter’s syndrome is manifested in his thoracolumbar spine and bilateral shoulders. To the extent possible, the examiner should distinguish between the symptoms and impairment attributable to the service-connected Reiter’s syndrome and any symptoms associated with his service-connected lumbar spine degenerative arthritis, right shoulder tendonitis, left shoulder tendonitis, or another nonservice-connected disorder. If the examiner cannot separate the symptoms, he or she should so state in the report. (d) The examiner is asked to estimate the degree of range of motion for passive motion, weight-bearing, and non-weight-bearing for chronic joint residuals for the examinations prior to September 27, 2019. The examiner should indicate whether the Veteran would have experienced any limitation of motion attributable to pain and at what point during the range of motion. Specifically, the examiner should address the following joints and examinations: (1) October 2008 VA examinations (bilateral ankles, elbows, knees, wrists, and hands/fingers); (2) June 2014 VA examinations (knees and cervical spine); (3) January 2017 VA examination (knees and cervical spine); and (4) September 2019 (cervical spine). (e) The examiner is asked to describe whether pain significantly limited functional ability during flares, and indicate range of motion during flares (the examiner must glean information regarding the flares’ severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources). If there was no pain and/or no limitation of function, such facts must be noted in the report. Specifically, the examiner should address the following joints and examinations: (1) June 2014 VA examination (cervical spine); (2) January 2017 VA examinations (ankles, cervical spine, hands, and knees); and (3) March 2018 VA examinations (hands and knees). (f) While a current examination would not be fruitful in addressing the period prior to September 27, 2019, the examiner may contact the Veteran to solicit information as to the functional limitation he remembers experiencing. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the examiner should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. (Continued on the next page)   2. Reajudicate the claim taking into account all applicable Diagnostic Codes and rating by analogy as necessary. The AOJ should identify and consider whether the Veteran is entitled to separate ratings for non-orthopedic chronic residuals of Reiter’s syndrome, to include eye conditions, skin conditions, prostatitis, and IBS. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Wulff, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.