Citation Nr: 21066870 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 18-47 847 DATE: November 2, 2021 ORDER Entitlement to a 30 percent rating for colitis is granted. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and unspecified depressive disorder, is remanded. FINDING OF FACT The Veteran's service-connected colitis manifested moderately severe colitis with frequent exacerbations. CONCLUSION OF LAW The criteria for entitlement to a 30 percent rating for colitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.114, Diagnostic Code 7323. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from July 1976 to July 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 and June 2018 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Entitlement to a 30 percent rating for colitis. The Veteran contends that he is entitled to a higher rating for his service-connected colitis because his symptoms have increased in severity. During the July 2021 Board hearing, the Veteran testified that his symptoms began in the 1980s. He bled two to three times a week from his rectum. In 1991, he had a hemorrhoid operation, but he still bled two to three times a week. He also took steroids and suppositories 5 to 6 times per week and he also experienced bowel movements with blood and stomach cramping. He had to carry wipes and extra pants when he traveled. He also adjusted his diet to counteract effects of colitis. His exercise was limited to walking. See also August 2015 Statement; June 2016 Notice of Disagreement. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran's service-connected colitis is rated 10 percent disabling effective from May 5, 2015, under 38 C.F.R. § 4.114 diagnostic code (DC) 7323. Under this code, a 10 percent rating is warranted for moderate symptoms with infrequent exacerbations. A 30 percent rating is warranted for moderately severe symptoms with frequent exacerbations. A 60 percent rating is warranted for severe symptoms with numerous attacks a year and malnutrition, the health only fair during remissions. A 100 percent rating is warranted for pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as liver abscess. See 38 C.F.R. § 4.114, DC 7323. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. Evidence The Veteran was evaluated in May 2015. Examination revealed symptoms of periodic diarrhea and anemia with occasional episodes of bowel disturbance. He was evaluated again in April 2016. The Veteran reported that he used mesalamine suppository and rectal aspirin. Examination revealed symptoms of diarrhea 2 to 3 times per week, abdominal distension continuously, and rectal bleeding 4 to 5 times a week. He also experienced occasional episodes of bowel disturbance with abdominal distress. Post-service treatment records indicate the Veteran's symptoms increased in severity. See e.g., December 2015 Gastroenterology Note (use mesalamine enema since 2014 but experience persistent bleeding); May 2017 Nursing Note (two fleet enemas given due to bleeding); October 2018 Primary Care Note (complained of abdominal cramping). In March 2019, the Veteran completed a follow up visit and complained of intermittent blood 1 to 2 times per week and ongoing use of mesalamine suppositories. The Board finds that the overall evidentiary record supports a rating of 30 percent disabling for colitis effective April 7, 2016. The Veteran's symptoms more nearly approximated moderately severe symptoms with frequent exacerbations. The Veteran gave an account of his daily routine for hygiene, dietary needs, and exercise limitations during the Board hearing. Medical evidence indicated the Veteran had persistent bleeding and an increased need for medication. The April 2016 examination indicated the Veteran had rectal bleeding 4 to 5 times per week. In addition, the Veteran described the effects of his disability on his mental status. The Board finds that the Veteran's colitis does not warrant the next higher 60 percent evaluation under DC 7323. There is no evidence to support that the Veteran has severe symptoms with numerous attacks a year and malnutrition. Accordingly, a disability rating of 30 percent, but no higher, for colitis is warranted. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disability is remanded. The Veteran contends that he developed PTSD because of his military service. In a March 2004 Statement, the Veteran wrote that his PTSD stressor stemmed from the Jim Jones massacre in Guyana. He was stationed at the Roosevelt Rose Naval Base in Puerto Rico. This was the base the dead bodies in the massacre were brought to before being sent back to the United States. The Veteran wrote that he saw and smelled the bodies. This event caused his PTSD stressor. The claim was denied in a September 2013 rating decision because the stressor could not be verified, there was no in-service notations of a psychiatric disorder, and post-service treatment records did not show a current diagnosis. The December 2014 and June 2018 rating decision did not reopen the claim, because the evidence submitted was not new and material. During the Board hearing, the Veteran testified that he became depressed because of his service-connected colitis. He testified that his disabilities caused him extreme embarrassment and mental distress. He also stated that he was previously diagnosed with unspecified depressive disorder. See February 2017 Psychiatric Note (major depressive disorder, PTSD); June 2017 Mental Health Treatment Plan Note (depressed and anxious mood with disrupted sleep). The February 2018 VA examination found that the Veteran did not meet the DSM-V criteria for PTSD and his psychiatric disability was not related to his military service. However, the examination did not provide an opinion on whether the Veteran's psychiatric disability was secondary to his service-connected disabilities. In Clemons v. Shinseki, the Court held that the scope of a claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant's description of the claim. 23 Vet. App. 1 (2009). The Board finds that the Veteran's testimony constitutes new and material evidence. The claim is reopened and expanded to include all psychiatric disabilities. Remand is required to obtain a medical opinion for secondary service connection. The matters are REMANDED for the following action: 1. Obtain any outstanding medical records and associate the with the claims file. (Continued on the next page) 2. Then, schedule the Veteran for a VA examination to determine whether the Veteran has a psychiatric disability that is secondary to a service-connected disability. A complete copy of the Veteran's claim file, including a copy of this remand, must be provided to the examiner for review. The examiner is asked to determine whether the Veteran has an acquired psychiatric disability secondary to any service-connected disabilities. A complete rationale must be provided for any opinion rendered. If an opinion cannot be rendered without resulting to mere speculation, the examiner must explain why this is so. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. 3. After completing the above actions, readjudicate the claim on appeal. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harris, Attorney Advisor 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.