Citation Nr: 21066510 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 16-15 807A DATE: November 1, 2021 REMANDED Entitlement to a rating in excess of 30 percent for the service-connected pruritus ani, effective March 17, 2015, is remanded. REASONS FOR REMAND The Veteran had active service from July 1952 to July 1956. This matter returns to the Board of Veterans' Appeals (Board) following a June 2021 remand from the United States Court of Appeals for Veterans Claims (Court). At that time, the Court granted a Joint Motion for Partial Remand (JMPR) in which the parties agreed that the Board's May 2020 denial of an increased rating for the service-connected pruritus ani failed to address adequately the Veteran's assertion of worsening of his pruritus ani symptoms. The JMPR also found that pertinent medical records were not obtained and associated with the claim file. The May 2020 Board decision and the June 2021 Court remand are incorporated herein by reference. This appeal has been advanced on the docket of the Board, pursuant to 38 C.F.R. § 20.900(c). Increased Rating for Service-Connected Pruritus Ani The Veteran asserts worsening of his service-connected pruritus ani of sufficient degree to warrant a disability rating in excess of 30 percent. Specifically, he describes "stains and blood" on his underpants requiring changing two to three times a dayas well as pain at night. See April 2015 Notice of Disagreement. In an April 2016 handwritten note, he states that he was "constantly changing [his] diaper and pads." In a January 2018 statement, his wife explained that his condition caused a decrease in social activities and that she applied his medication on a "constant basis." The Board's previous decision relied solely on the clinical findings rendered by medical examinations (as set forth in the treatment records) and found that such clinical findings considered the Veteran's lay statements and reported history. However, the Court found that no VA medical examiner considered the Veteran's reported symptoms of bleeding from scratching or the Veteran's wife's report of the need for constant use of ointments. As such, a remand is necessary in order to obtain an additional medical opinion addressing these matters. The Court also found that the claims file is absent of pertinent medical records including, records from St. Vincent's Hospital in which the Veteran was hospitalized for a seizure, and records from Encompass Health Lakeshore Rehabilitation in which he received rehabilitation services. See October 2019 VA Primary Care Outpatient Note. Such records may contain information as to his use of absorbent pads or other relevant symptomatology related to his pruritus ani. Therefore, to satisfy VA's duty to assist, the Board must ensure such records are obtained and associated with the Veteran's claim file. Accordingly, this matter is REMANDED for the following action: 1. Obtain any outstanding private treatment records pertaining to the Veteran's treatment for his service-connected pruritus ani, to include records from St. Vincent's Hospital and Encompass Health Lakeshore Rehabilitation, and associate them with the claims file. All requests and responses for the records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 2. Then, schedule the Veteran for an examination with an appropriate VA clinician to determine the current severity of his service-connected pruritus ani. The entire claims file must be made available to, and be reviewed by, the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported. The examiner should provide a full description of this disability (including all associated signs and symptoms). In providing the evaluation, the examiner must address the Veteran's statements including, his reported symptoms of bleeding from scratching and his wife's report of the need for constant use of ointments. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a scheduled VA medical examination may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. R. Bobb, Associate 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.