Citation Nr: 21061793 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 16-35 867 DATE: October 5, 2021 ORDER Entitlement to an evaluation in excess of 30 percent for diverticulosis with GERD is denied. Entitlement to an evaluation in excess of 20 percent for degenerative joint disease of the lumbar spine is denied. Entitlement to an evaluation in excess of 20 percent for hemorrhoids is denied. REMANDED Entitlement to service connection for atrial fibrillation is remanded. Entitlement to service connection for cardiomyopathy is remanded. Entitlement to service connection for hypertensive heart disease is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to special monthly compensation due to loss of use of a creative organ is remanded. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's diverticulosis with GERD has been manifest by persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 2. The Veteran's lumbar spine disability is manifest by flexion of no less than 45 degrees, and is not manifested by ankylosis. 3. The Veteran's service-connected hemorrhoids is assigned a 20 percent rating, which is the maximum schedular rating authorized for hemorrhoids under Diagnostic Code 7336. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for diverticulosis with GERD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.114, Diagnostic Codes 7301, 7319, 7327, 7346 (2019). 2. The criteria for a rating in excess of 20 percent for s lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2019). 3. The criteria for a rating in excess of 20 percent for hemorrhoids have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1975 to September 1997. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This matter was previously before the Board in January 2020. The Veteran was afforded a hearing before the undersigned in August 2019. A transcript of the hearing is of record. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. A Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to an evaluation in excess of 30 percent for diverticulosis with GERD The Veteran contends that he is entitled to a higher rating for his diverticulosis with GERD. The Rating Schedule states that there are diseases of the digestive system which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding. 38 C.F.R. §§ 4.113, 4.114. The Rating Schedule prohibits Diagnostic Codes 7301 to 7329 inclusive, 7331, 7342, and 7345 to 7348 inclusive, from being combined with each other. A single rating will be assigned under the Diagnostic Code that compensates the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran's diverticulosis with GERD is rated under Diagnostic Codes 7346-7327. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 7346 is used to rate hiatal hernia. Under Diagnostic Code 7346, a maximum 60 percent rating is assigned where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptoms combinations productive of severe impairment of health. A 30 percent rating is assigned where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. A 10 percent rating is assigned when two or more of the symptoms for the 30 percent rating are present with less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. Diverticulitis is rated as irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending upon the predominant disability picture. 38 C.F.R. § 4.114, Diagnostic Code 7327. The criteria for irritable colon syndrome, or irritable bowel syndrome, provide a 30 percent rating is assigned for severe irritable colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal stress. A 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A 0 percent rating is assigned for mild irritable colon syndrome with disturbances of bowel function with occasional episodes of abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. The criteria for rating adhesions of the peritoneum provide a maximum 50 percent rating for severe adhesions of peritoneum, definite partial obstruction shown by x-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. A 30 percent rating is assigned for moderately severe adhesions of peritoneum, partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. 38 C.F.R. § 4.114, Diagnostic Code 7301. Ratings for adhesions will be considered when there is history of operative or other traumatic or infectious (intra-abdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, or presence of pain. 38 C.F.R. § 4.114, Diagnostic Code 7301, Note. The criteria for rating ulcerative colitis provide a 100 percent rating for pronounced ulcerative colitis, resulting in marked malnutrition, anemia, and general debility, or with some serious complication as liver abscess. A 60 percent rating is assigned for severe ulcerative colitis with numerous attacks a year and malnutrition, with health only fair during remissions. A 30 percent rating is assigned for moderately severe ulcerative colitis with frequent exacerbations. 38 C.F.R. § 4.114, Diagnostic Code 7323. In assigning a rating under DC 7346, the Board may not consider the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Board finds that the Veteran's diverticulosis with GERD manifested in persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, warranting no more than the 30 percent rating currently assigned. The Veteran was afforded a VA esophageal conditions examination in December 2012. He was confirmed to have a diagnosis of GERD. The Veteran reported symptoms of heartburn, indigestion, regurgitation, abdominal pain, diarrhea and constipation. He was noted to be taking continuous medication to treat his condition, including Omeprazole. On evaluation, the Veteran's symptoms were noted to include pyrosis; reflux; regurgitation; sleep disturbance caused by esophageal reflux four or more times per year, lasting one to nine days; anemia; and mild nausea four or more times per year, lasting less than one day. There was no esophageal stricture, spasm or diverticulum. In addition, no functional impact was noted. The Veteran was afforded another VA examination in November 2020. He was confirmed to have a diagnosis of GERD. The Veteran reported symptoms of acid reflux with burning esophageal pain, especially when eating a meal. He also indicated his condition has remained the same since its onset. He was noted to be taking continuous medication to treat his condition, including Omeprazole. On evaluation, the Veteran's symptoms were noted to include pyrosis; reflux; regurgitation; and sleep disturbance caused by esophageal reflux four or more times per year, lasting less than one day. There was no esophageal stricture, spasm or diverticulum. In addition, no functional impact was noted. Review of private medical records shows that the Veteran underwent a colonoscopy in April 2013. He was assessed to have mild diverticulosis and hemorrhoids. The Veteran submitted a private assessment dated in August 2019. Dr. J.N. commented that all gastroenterology notes she reviewed comment on diverticulosis, gastric erosions, gastritis duodenitis, but no hiatal hernia. She further noted that there was no evidence of diverticulitis or IBS on colonoscopy. As noted above the Veteran reported his subjective symptoms relating to his gastrointestinal disability, and the Board finds these lay reports credible, as they are consistent with the objective medical evaluations of record. The Board finds, based on a review of the pertinent evidence of record, that the Veteran's GERD with diverticulosis manifested in persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health throughout the appeal period, corresponding to the criteria for a 30 percent rating under DC 7346. A higher 60 percent rating under DC 7346 is not warranted unless there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. As noted above, the Veteran reported symptoms including heartburn, indigestion, regurgitation, abdominal pain, diarrhea and constipation. Objective medical testing showed pyrosis; reflux; regurgitation; sleep disturbance; anemia; and nausea. However, notably absent from the Veteran's reported and assessed symptomatology are weight loss, hematemesis and melena. Furthermore, the November 2020 VA examiner not only assessed that the Veteran does not have severe impairment as a result of his gastrointestinal symptoms, but also declined to assess that the impairment even rose to the level of "considerable". The Board reiterates that the Veteran himself reported his symptomatology has remained consistent as of the onset of his disability. Thus, the Board concludes that the Veteran's GERD with diverticulosis did not more nearly approximate a combination of symptoms productive of severe impairment of health. A higher 60 percent rating under DC 7346 is not warranted. The Board has also considered whether a higher rating should be assigned for diverticulitis under Diagnostic Code 7327, which allows for rating based on irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending on the predominant disability picture. The Board notes, however, there is no evidence of record indicating peritoneal adhesions, or symptoms thereof. Therefore, a higher rating under Diagnostic Code 7301 for peritoneal adhesions is not warranted. In so finding, the Board acknowledges that the Veteran has described recurrent diarrhea. However, the Veteran would not receive a higher rating under Diagnostic Code 7319 for irritable colon syndrome, as a 30 percent rating is the highest rating allowed under that code. Regarding Diagnostic Code 7323 for ulcerative colitis, the Board finds that there is no diagnosis of record indicating ulcerative colitis. Also, the evidence of record does not show malnutrition, general debility or any serious complication, such as liver abscesses. Therefore, the Board finds that a rating on the basis of ulcerative colitis is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 30 percent for the Veteran's diverticulitis with GERD at any time during the appeal period, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102. 2. Entitlement to an evaluation in excess of 20 percent for degenerative joint disease of the lumbar spine The Veteran contends that he is entitled to a higher rating for his lumbar spine disability. The Veteran's lumbar spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised Diagnostic Codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, DC 5242 was only applicable to degenerative arthritis of the spine. As of February 7, 2021, under the amended criteria, DC 5242 was expanded to include degenerative arthritis and degenerative disc disease other than intervertebral disc syndrome. Also prior to the regulatory change, DC 5243 instructed that intervertebral disc syndrome (preoperatively or postoperatively) be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. As of February 7, 2021, under the amended criteria, DC 5243 is only assignable when there is disc herniation with compression and/or irritation of the adjacent nerve root; and Diagnostic Code 5242 is to be assigned for all other disc diagnoses. Finally, prior to February 7, 2021, Diagnostic Code 5010 instructed that arthritis due to trauma, substantiated by x-ray findings was to be rated as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010. In turn, degenerative arthritis, established by X-ray findings, was to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. As of February 7, 2021, under the amended criteria, Diagnostic Code 5010 clarified that post-traumatic arthritis is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. The x-ray finding requirement was eliminated. DC 5003 remains unchanged. The Board notes that the General Rating Formula for Diseases and Injuries of the Spine remains unchanged. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA back examination in December 2012. He was confirmed to have a diagnosis of degenerative joint disease of the lumbar spine and intervertebral disc syndrome (IVDS). The Veteran reported flare ups, productive of pain, stiffness and difficulty bending. Physical evaluation showed that forward flexion was limited to 60 degrees; extension was limited to 20 degrees; right lateral flexion was limited to 20 degrees; left lateral flexion was limited to 20 degrees; right lateral rotation was limited to 20 degrees; and left lateral rotation was limited to 20 degrees. Repetitive use testing with three repetitions showed the same range limitations. No additional limitation in range of motion was identified after repetitive use testing, though functional impairment with less movement than normal and pain on movement was acknowledged. The Veteran was also noted to have localized tenderness and pain to palpation. No guarding or muscle spasm was noted. There was no muscle atrophy. Reflex and sensory exams were normal. Straight leg raising test was normal. Radiculopathy was noted as moderate left lower extremity intermittent pain. The Veteran was noted to have IVDS, but without any incapacitating episodes requiring bed rest prescribed by a physician. Functional impact was noted as inability to lift heavy objects or perform physical activities. The Veteran was afforded another VA spine examination in November 2020. His diagnoses of lumbar degenerative joint disease and IVDS were confirmed. The Veteran reported low back pain, stiffness, radiating pain and numbness. Flare ups were also reported, producing intense pain and stiffness, lasting a few days or more. Functional loss was noted to include difficulty with forward flexion, heavy lifting and driving. Physical evaluation showed that forward flexion was limited to 60 degrees; extension was limited to 20 degrees; right lateral flexion was limited to 20 degrees; left lateral flexion was limited to 20 degrees; right lateral rotation was limited to 20 degrees; and left lateral rotation was limited to 20 degrees. Abnormal range of motion was noted to inhibit bending, twisting and lifting ability. Pain was noted on forward flexion, extension and rotation panes. Repetitive testing with three repetitions yielded no additional loss of motion. The examiner further explained that there is no additional range of motion loss on repetitive use over time, but heavy and repeated activity worsens pain which inhibits ability to continue tasks. Flare ups were noted to further limit motion. Specifically, forward flexion was estimated to be limited to 45 degrees; extension was estimated to be limited to 15 degrees; right lateral flexion was estimated to be limited to 15 degrees; left lateral flexion was estimated to be limited to 15 degrees; right lateral rotation was estimated to be limited to 15 degrees; and left lateral rotation was estimated to be limited to 15 degrees. There was no guarding or muscle spasm. Muscle strength was normal. Reflex exam showed hypoactive knees and left ankle. Sensory exam showed decreased sensation in all areas except the right upper anterior thigh. There was no ankylosis. Radiculopathy was identified in the bilateral femoral and sciatic nerves mild on the right and moderate on the left. While the Veteran was noted to have IVDS, there were no incapacitating episodes requiring bed rest prescribed by a physician. The Veteran used no assistive devices. The Board acknowledges the VA and private spine treatment notes of record. These show regular complaints of back pain with radiating pain to the lower extremities. Furthermore, the Veteran underwent surgery in July 2016, including a lumbar hemilaminectomy and decompression at L4-5 and L5-S1. The Veteran was diagnosed with a disc herniation in January 2015. The Board also acknowledges the private medical opinion of Dr. J.N. dated in August 2019. This private evaluator circled the 20 percent rating under DC 5003, stating the earliest MRI of record shows lumbar degenerative disease and arthropathy; circled the 60 percent rating under DC 5243 for IVDS, stating that the Veteran has advanced disease, had surgery in 2016, a history of multiple injections, chronic pain and surgical appointments; and circled the 20 percent rating under the general rating formula for spine disabilities stating this opinion was based on examination and specialist evaluation findings. The Board acknowledges the Veteran's lay statements of record including testimony before the undersigned during an August 2019 hearing. The Veteran went over the medical notes of record, including the aforementioned private evaluator's findings, and described his symptoms of pain, including radiating pain. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for a lumbar spine disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, pain with repetitive use, pain during flare-ups, pain during repetitive use over time, difficulty with bending, lifting and prolonged strenuous activity. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. In this regard, the December 2012 VA examiner clearly indicated that there is no additional loss of motion on repetitive use testing only limited duration of activity. Similarly, the November 2020 VA examiner estimated the Veteran's limitation of flexion on flare up to be 45 degrees at worst. Furthermore, at no point during the appellate period has an orthopedist evaluated or estimated limitation of flexion to be less than 45 degrees, even during flare-ups or after repetitive motion nor has the Veteran been diagnosed with ankylosis. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. In this regard, both the December 2012 and November 2020 VA examiners acknowledged the Veteran's IVDS, but also both noted that there is no evidence of incapacitating episodes requiring prescribed bed rest by a physician. Additionally, in the rationale claiming a 60 percent rating is warranted, the Veteran's own private examiner failed to note that the Veteran had any incapacitating episodes requiring bed rest prescribed by a physician. The Veteran also did not testify he had such episodes during the appellate period. Effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." While the Veteran does have a disc herniation diagnosis, there is again no evidence that he was prescribed bedrest for at least 4 weeks. 38 C.F.R. § 4.71a, Diagnostic Code 5243. As such, a higher disability rating is not warranted on the basis of incapacitating episodes, and a discussion of the amended regulation is not warranted. Furthermore, the Board notes that throughout this period on appeal, the Veteran's record does not reflect a diagnosis of traumatic arthritis. Therefore, a rating under DC 5010 is not applicable. Instead, the Veteran is clearly diagnosed with degenerative arthritis. See December 2012 and November 2020 VA examinations. Thus, the Veteran is correctly evaluated under the General Rating Formula for Diseases and Injuries of the Spine based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Regarding neurological impairment, the Veteran has already been granted service connection for bilateral lower extremity radiculopathies and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for a lumbar spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an evaluation in excess of 20 percent for hemorrhoids The Veteran asserts that his hemorrhoids are more severe than currently evaluated. His hemorrhoids are evaluated as 20 percent disabling. For external or internal hemorrhoids, under Diagnostic Code 7336, a noncompensable rating is assigned for mild or moderate hemorrhoids. 38. C.F.R. § 4.114. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Id. A December 2012 VA examination shows a diagnosis of hemorrhoids. Current symptoms were reported to include bleeding, itching, diarrhea, constipation and pain. The examiner indicated that the Veteran's hemorrhoids were of moderate severity; large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; with persistent bleeding; and with secondary anemia. In addition, pruritus ani was identified. No functional impact was noted. A November 2020 VA examination shows a diagnosis of hemorrhoids and pruritus ani. Hemorrhoids were assessed to be mild or moderate, productive of itching, pain, protrusion and leading. Examination showed no external hemorrhoids only skin tags. No functional impact was noted. As the Veteran's hemorrhoid disability has been rated at the maximum level allowable under the Diagnostic Code for the disability as diagnosed, a rating in excess of 20 percent cannot be assigned. Although other Diagnostic Codes may provide for higher ratings for rectum and anal disabilities, "when a condition is specifically listed in the Schedule, it may not be rated by analogy." Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). In this instance, the Veteran's diagnosis is hemorrhoids, which at most, may be afforded a 20 percent rating under the diagnostic criteria for that disability. There is no indication that the Veteran has any other separately ratable disability of the rectum/anus, including Diagnostic Codes 7332 (impairment of sphincter control), 7333 (stricture of rectum and anus), 7334 (rectum prolapse), and 7335 (fistula in ano). The Board acknowledges the Veteran's diagnosis of pruritus ani. However, under Diagnostic Code 7337, pruritus ani is rated based on the underlying condition. Both the December 2012 and November 2020 VA examiners noted the hemorrhoids issue leads to pruritus ani, and described the same symptoms for both conditions. As the Veteran has been evaluated and rated under Code 7336, a separate rating under 7337 is not warranted. The Veteran's hemorrhoids are rated 20 percent under Diagnostic Code 7336. 38 C.F.R. § 4.114. Under that diagnostic code, a 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. The maximum schedular rating available for hemorrhoids is 20 percent. 38 U.S.C. § 1155; 38 C.F.R. § 4.114; Smith v. Nicholson, 451 F.3d. 1344 (Fed. Cir. 2006). As there is no legal basis upon which to award a higher schedular rating, the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). REASONS FOR REMAND 1. Entitlement to service connection for atrial fibrillation is remanded. 2. Entitlement to service connection for cardiomyopathy is remanded. 3. Entitlement to service connection for hypertensive heart disease is remanded. The Veteran was last afforded a VA examination to assess the nature and etiology of his heart disabilities in November 2020. The examiner provided a negative etiological opinion, reasoning that the Veteran's May 1997 separation examination is silent for heart conditions; that an April 2000 echocardiogram only showed some mild left ventricular hypertrophy; that a May 2002 medical record indicates hypertension and previous episodes of Paroxysmal Atrial Fibrillation; but that there is no evidence of hypertension or heart disease between separation and 2000. The Board notes that absence of medical records in service is not, by itself, a sufficient basis for a rationale. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Furthermore, the Board finds this rationale internally inconsistent. The examiner on the one hand concedes there is evidence indicative of atrial fibrillation episodes prior to May 2002, and some left ventricular hypertrophy shown on testing 3 years after separation yet also reasons that there is no evidence of heart disease between the Veteran's separation from service in May 1997 and the April 2000 echocardiogram. Additionally, the Board notes that the Veteran credibly testified at a hearing before the undersigned in August 2019 that while he was on active duty, he would experience hard heartbeats, his heart would skip beats, and his heart would not return to normal rhythms after exertion. The examiner neither noted nor addressed these lay statements of record. Additionally, the Board notes that review of the record shows that the Veteran reported heart palpitations in a June 1998 report of medical examination; and an August 1998 cardiac evaluation showed marked sinus bradycardia with sinus arrhythmia. Therefore, the examiner's statement that there is no evidence of heart disease between 1997 and 2000 is simply inaccurate. The November 2020 VA heart examination is therefore inadequate for adjudication purposes. When VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical examination or opinion is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Another opinion should be sought on remand. 4. Entitlement to service connection for sleep apnea The Veteran was last afforded a VA examination to assess the nature and etiology of his sleep apnea in November 2020. The examiner provided a negative etiological opinion, reasoning that the Veteran's service records are silent for symptoms or complaints suspicious of sleep apnea such as snoring, frequent awakenings or morning headaches; and that the 2009 study showed relatively mild sleep apnea, consistent with a likely onset after service. The Board notes that absence of medical records in service is not in itself a sufficient basis for a rationale. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). However, the examiner also reasoned that the sleep study showed a "relatively mild" apnea in 2009, consistent with a likely onset after service. Nevertheless, the Board notes that the Veteran served overseas for over five years, including in Southwest Asia, and his MOS was power generator equipment repairer; his DD Form 2014 further indicates that the Veteran received training in hazardous materials waste handling. His service in Southwest Asia and MOS are indicative that he was exposed to environmental hazards in service. Furthermore, review of the Veteran's service records reflects that he did report congestion and difficulty breathing at night in February 1995. The aforementioned facts were specifically noted in the Board's January 2020 remand which the examiner was instructed to review and yet, the examiner made no mention of the Veteran's lay testimony or the in-service breathing complaints, or the environmental hazard exposures in Southwest Asia. In addition, the Board's remand instructions specifically directed the examiner to address etiological relationships to the Veteran's service-connected disabilities which was not undertaken by this examiner. The November 2020 VA sleep apnea examination is therefore inadequate for adjudication purposes. When VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical examination or opinion is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Another opinion should be sought. 5. Entitlement to service connection for erectile dysfunction is remanded. The AOJ obtained a November 2020 VA male reproductive examination and medical opinion. However, this medical opinion does not provide an adequate rationale regarding whether the Veteran's disability had its onset in service or is otherwise related to service. In this regard, the entirety of the examiner's rationale consists of the statement that available service records are silent for any erectile dysfunction issues. As noted above, the mere absence of treatment in service records is not a sufficient rationale. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current disability and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Another opinion should be sought. 6. Entitlement to special monthly compensation due to loss of use of a creative organ is remanded. Action on this claim is deferred pending resolution of the remanded claim for service connection for erectile dysfunction, as the claims are intertwined. There can be no special compensation for loss of use of a creative organ if a disability involving the creative organ is not service-connected. 7. Entitlement to a total disability rating based on unemployability (TDIU) is remanded. The Veteran's claim of entitlement to a TDIU is inextricably intertwined with his claims of entitlement to service connection remanded herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, the issue of entitlement to TDIU is remanded as intertwined and must be deferred until the adjudication of pending claims. Additionally, the Veteran did not complete a VA Form 21-8940 with regard to the claim for a TDIU. The RO should afford the Veteran an opportunity to submit a completed VA Form 21-8940. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file the Veteran's outstanding VA and private treatment records. 2. Thereafter, obtain an addendum medical opinion from an appropriate clinician to address the nature and etiology of his heart diseases, to include atrial fibrillation, cardiomyopathy and hypertensive heart disease. The examiner must provide a well-reasoned opinion as to whether it is at least as likely as not that the Veteran's heart disabilities began during service, or are otherwise etiologically related to service. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran's reports, the examiner must provide a rationale for doing so. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the opinion. This must be noted in the examination report. Hearing testimony dated in August 2019 as well as pertinent VA and private medical records must also specifically be addressed including reported heart palpitations in a June 1998 report of medical examination; and an August 1998 cardiac evaluation showing marked sinus bradycardia with sinus arrhythmia. The examiner is further advised that absence of evidence in service treatment records alone is an insufficient basis for a rationale. 3. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and etiology of his sleep apnea. The claims file, including this remand, must be provided to the examiner, who must note his or her review of the file. The examiner must outline the Veteran's clinical history, including information regarding the onset of symptoms. If an examination is deemed necessary, such must be arranged. The examiner must provide an opinion as to each of the following: a. Whether it is at least as likely as not that sleep apnea began in service or is otherwise etiologically related to the Veteran's time on active duty. b. Whether it is at least as likely as not that sleep apnea was caused by any of the Veteran's service-connected disabilities. c. Whether it is at least as likely as not that sleep apnea was aggravated by any of the Veteran's service connected disabilities. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran's reports, the examiner must provide a rationale for doing so. The examiner is further advised that absence of evidence in service treatment records alone is an insufficient basis for a rationale. The examiner must also specifically address the fact that the Veteran's service in Southwest Asia and MOS are indicative that he was exposed to environmental hazards in service; and the Veteran's report of congestion and difficulty breathing at night in February 1995. 4. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and etiology of his erectile dysfunction. The claims file, including this remand, must be provided to the examiner, who must note his or her review of the file. The examiner must describe the Veteran's clinical history, including information regarding the onset of symptoms. The examiner must provide a well-reasoned opinion as to whether it is at least as likely as not that the Veteran's erectile dysfunction began during service or is otherwise etiologically related to service. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran's reports, the examiner must provide a rationale for doing so. The examiner is further advised that absence of evidence in service treatment records alone is an insufficient basis for a rationale. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.