Citation Nr: A21020392 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 190225-91667 DATE: December 22, 2021 REMANDED Entitlement to an evaluation in excess of 10 percent for coccydynia is remanded. Entitlement to service connection for a low back disability, to include degenerative disc disease (DJD), as secondary to service connected coccydynia and/or residuals of surgical pilonidal cyst removal is remanded. REASONS FOR REMAND The Veteran served on active duty in the military from October 1968 to October 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA), was signed into law on August 23, 2017. This law created a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. The Veteran chose to participate in VA's test program RAMP, the Rapid Appeals Modernization Program, and this decision has been written consistent with the new AMA framework. The Veteran selected the Supplemental Claim lane when he submitted the RAMP election form in June 2018. Accordingly, the February 2019 RAMP rating decision considered the evidence of record prior to that date. The Veteran timely appealed the RAMP rating decision in February 2019, opting for a hearing by the Board. Thus, the Board may only consider the evidence of record at the time of the February 2019 RAMP rating decision, as well as evidence submitted by the Veteran or his representative at the April 2021 Board hearing and within 90 days following the hearing. 38 C.F.R. § 20.302 (a). Initially, the Board notes that the February 2019 rating decision found that new and relevant evidence had been received to readjudicate the appeal. This is a favorable finding by the agency of original jurisdiction (AOJ), and the Board need not consider whether to reopen/reconsider the claim. Thus, the Board will proceed to the address the claim on the merits. See 38 U.S.C. § 5104A ; 38 C.F.R. § 3.104 (c). The Veteran seeks entitlement to a rating in excess of 10 percent for his service connected coccydynia (also referred to as tailbone a disability) and service connection for a back disability, to include DJD, as secondary to coccydynia and/or residuals of surgical pilonidal cyst removal. The Board finds that more development is necessary prior to final adjudication of the claim on appeal. VA medical treatment records show the Veteran has a history of treatment for low back pain/sciatica and sacral pain associated with a pilonidal cyst excision. See e.g., Palo Alto VA medical center (MC) medical treatment record, dated November 2, 2018. He complained that chronic pain keeps him from sitting comfortably and completing activities of daily living. See Palo Alto VAMC treatment record, dated May 26, 2017. The Veteran currently takes oral codeine and was previously treated with gabapentin, topical analgesics, and lidocaine ointment. See Palo Alto VAMC medical treatment record, dated November 2, 2018. Notably, in June 2017, the Veteran was evaluated at general surgery for chronic pain over the coccyx. See Palo Alto VAMC medical treatment record, dated June 22, 2017. He reported trouble with sitting, standing up straight, and just being uncomfortable in all positions. Upon examination, the provider, a physician's assistant, noted a well healed scar in the gluteal cleft and tenderness, with light palpitation, from the sacrum all the way down to the coccyx. Severe point tenderness was illustrated over the coccyx. The provider found it was slightly unusual for the Veteran to experience point tenderness over the coccyx based on his scar and the surgery but explained that with any surgery there was a risk of chronic pain due to transection of tissue and nerves that may supply the area and any resulting scar tissue/fibrosis. Further, there was no surgical treatment available to help with his chronic pain. Id. The June 2017 VA provider indicated it was challenging to comment on the original pilonidal operation and the sequalae without access to the records and opined that it was unclear whether the pain over the Veteran's coccyx was related to the incident. Further, the physician's assistant provided that the Veteran's lumbar DJD was completely unrelated to his previous pilonidal disease; however, it was unclear if some of the Veteran's pain was related to his previous epidural abscess in 2011. Id. The Veteran last underwent VA examination for coccydynia in June 2013. The examiner completed a VA skin disability benefits questionnaire identifying the diagnoses of pilonidal cyst and coccydynia. See June 2013 VA Skin Examination. Notably, the examiner also indicated that the Veteran had a lumbosacral paraspinal abscess in 2012, which may or may not be related to the disturbed anatomy in the lower back/ gluteal area due to the pilonidal cyst or the related surgical treatment. Id, at 2. The Veteran was noted to be a reliable historian as the examination was consistent with an increase in symptoms of the pilonidal cyst and related surgical treatment. The examiner determined the Veteran's pain in the intergluteal region greatly affected his job as the owner of a marine mechanics business because he had to turn down job opportunities that required travel because prolonged sitting caused too much pain. Also, pain prevented him from bending at the hips to maneuver into low, tight places while working, while the side effects of narcotic left him feeling "knocked out" and groggy. Id, at 3. The Veteran underwent a VA back examination in January 2015, and the diagnosis of pilonidal cyst status post excision and DJD of the spine was confirmed. The examiner also noted the Veteran had a history of epidural paraspinal abscess in 2011 that was thought, at the time, to have originated from an infected tooth. See January 2015 VA Back Examination, at 2. The Veteran reported flareups occur with prolonged sitting and cause worsening pain and numbness. The examiner found the Veteran had decreased range of motion of the spine and moderate, left lower extremity radiculopathy involving the L4/L5/S1/S2/S3 sciatic nerve roots. The examiner determined the Veteran's back disability would impact his ability to work, as his back would interfere with his ability to bend, lift, and carry. Id., at 9. The examiner explained that the pilonidal cyst excision was asymptomatic upon examination in 1974, and as the Veteran's tailbone pain, DJD, and spinal epidural abscess developed much later, therefore opined that they were not related to the original pilonidal cyst or its treatment. Id. 1. Increased Disability Evaluation for Coccydynia The Veteran contends he is entitled to a rating in excess of 10 percent for his tailbone disability, as the pilonidal cyst and subsequent surgical removal were not ordinary and resulted in unresolved chronic pain that worsened over the years. He testified that the pain was like straddling a fence pole all day. See April 2021 Board Hearing Transcript, at 9. Moreover, he asserts that his medications, which include codeine, markedly interfere with his ability to run his marine engine repair shop. See Id., at 6; Notice of Disagreement, received April 2, 2015. At 10 percent, the Veteran currently receives the highest schedular rating for coccydynia secondary to surgery for pilonidal cyst associated with postoperative pilonidal cyst, under diagnostic code 5299-5298. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part followed by "99." Hence, the Veteran's residuals of coccyx spine fracture have been evaluated by analogy, using the criteria for removal of the coccyx under 38 C.F.R. § 4.71a, DC 5298. Under Diagnostic Code 5298, a noncompensable evaluation is assigned for partial or complete removal of the coccyx, without painful residuals, and a maximum 10 percent evaluation is assigned for removal of the coccyx with painful residuals. 38 C.F.R. § 4.71a, DC 5299-5298. VA may consider an extraschedular rating in cases that are exceptional, such that the standards of the rating schedule appear to be inadequate to evaluate a disability. 38 C.F.R. § 3.321 (b)(1). Extraschedular ratings under 38 C.F.R. § 3.321 (b)(1) are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. The Board does not have the authority to assign, in the first instance, higher ratings on an extraschedular basis under 38 C.F.R. § 3.321 (b)(1). The Veteran has coccydynia due to surgical removal of a cyst that resulted in loss of structural material. Although the Veteran has not had his tailbone removed, either partially or complete, the record establishes that he has pain in the coccyx area and is not a surgical candidate. He also has a history of paraspinal abscess, but his private VA provider was unclear on whether it contributed to his tailbone pain; however, the June 2013 VA examiner indicated the abscesses may be related to the disturbed anatomy in the lower back/gluteal area due to pilonidal cyst, but failed to indicate if some of the Veteran's pain was attributed to the abscesses. Notably, the VA examiner specifically found the Veteran's intergluteal pain greatly affected his job as the owner of a marine mechanics business. Considering the above, the Board finds that at the time of the last prior rating decision, the record showed that the Veteran's coccydynia may have represented an exceptional or unusual disability picture based on marked interference of employment. The June 2013 VA examination for the Veteran's coccydynia was not provided in conjunction with the instant claim, and the report did not differentiate between the Veteran's service connected coccydynia and non-service connected low back disability. VA's duty to assist a Veteran includes providing a thorough and contemporaneous examination when the record does not adequately reveal the current state of the Veteran's disability. Hart v. Mansfield, 21 Vet. App. 505, 508 (2007) (citing, inter alia, Green v. Derwinski, 1 Vet. App. 121, 124). Thus, a remand based on this pre-decisional duty to assist error is warranted. Accordingly, the issue of entitlement to an evaluation in excess of 10 percent for coccydynia is remanded for an examination. 2. Service Connection for a Low Back Disability, to include DJD, as Secondary to Coccydynia and/or Residuals of Surgical Pilonidal Cyst Removal The Veteran contends his low back disability, including DJD, is secondary to his service connected coccydynia. He asserts that the surgical removal of his incredibly large pilonidal cyst was not a routine procedure, as a pound of structural tissue was removed that resulted in a two week hospitalization, continuing pain, and a compromised lower spine. See Statement in Support of Claim, received June 7, 2018. The Veteran reported that it took months for the wound to heal, but he was still bothered by pain, which became much worse over time. Id. He testified that he has experienced back pain since the cyst was removed, and the pain in his back is not the same as the coccyx pain. See April 2021 Board Hearing Transcript, at 4. Considering the record, the Board finds that the Veteran has yet to undergo a VA examination that adequately addressed whether his back disability was caused or aggravated by the service connected coccydynia. In providing a negative nexus opinion, the January 2015 examiner provided that the Veteran's back disabilities developed much later than the pilonidal cyst, which were asymptomatic in 1974, and therefore failed to consider the Veteran's reports as to onset and continuity of symptomatology. Further, the examiner did not provide an opinion as to whether the Veteran's back disability was aggravated by his coccydynia, to include the surgical pilonidal cyst removal residuals. When VA undertakes to provide a VA examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, a new VA examination that addresses causation and aggravation, while considering the Veteran's lay statements is warranted. Accordingly, the issue of service connection for a low back disability, to include DJD, as secondary to service connected coccydynia and/or residuals of surgical pilonidal cyst removal is remanded to provide the Veteran with a VA examination and etiological opinion as there exists a pre-decisional duty to assist error. The matters are REMANDED for the following action: 1. Schedule the Veteran for separate VA examinations to evaluate the nature and severity of his coccydynia and low back disability, to include DJD. All indicated tests and studies should be performed and findings reported in detail. The claims folder must be made available to the examiner for review prior to examination. The examiner is asked to provide an opinion as to the whether the Veteran's coccydynia alone affects his ability to work or perform the activities of daily living. In providing the opinion, the examiner should distinguish between the symptoms of the Veteran's service connected coccydynia and low back disability. The examiner should explain if he/she is unable to delineate the symptoms. Then, the examiner is asked to provide an opinion as to the whether it is at least as likely as not that any low back disability, to include DJD, was incurred in or is otherwise related to an in-service injury, event, or disease. The examiner should also opine whether it is at least as likely as not that any low back disability, to include DJD, was 1) more likely than not (50 percent or greater probability) caused by his service connected coccydynia and/or residuals of surgical cyst removal and 2) more likely than not (50 percent or greater probability) aggravated (worsened beyond the natural progression of the disability) by his service-connected coccydynia. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 2. After completion of the above, and if warranted, refer the Veteran's claim for an increased rating for service-connected coccydynia to the Director of the Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 3.321 (b)(1). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.