Citation Nr: 21021769 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-19 640 DATE: April 13, 2021 ORDER Entitlement to an initial rating in excess of 10 percent from January 23, 2010 to September 1, 2020, for bilateral pes planus is denied. Entitlement to a rating in excess of 30 percent since September 2, 2020, for bilateral pes planus is denied. Entitlement to an initial rating in excess of 20 percent for bipolar disorder is denied. Entitlement to an initial compensable rating from January 23, 2010 to October 5, 2011, for restrictive lung disease is denied. Entitlement to service connection for left ankle ligamentous laxity is granted. Entitlement to service connection for right ankle peroneal ligamentous laxity is granted. REMANDED Entitlement to a rating in excess of 30 percent since October 6, 2011 for restrictive lung disease is remanded. Entitlement to service connection for a gastroesophageal disability, to include gastroesophageal reflux disease (GERD), is remanded. Entitlement to service connection for an intestinal disability, to include irritable bowel syndrome (IBS), is remanded. FINDINGS OF FACT 1. From January 23, 2010 to September 1, 2020, the Veteran’s bilateral pes planus was manifested by pain on manipulation and pain accentuated on use; it was not manifested by marked abduction, marked pronation, swelling, callosities, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. 2. Since September 2, 2020, the Veteran’s bilateral pes planus was manifested by pain on manipulation and pain accentuated on use; there was no evidence of marked abduction, marked pronation, swelling, callosities, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. 3. At its worst, the severity of the Veteran’s bipolar disorder is unchanged from its pre-aggravation baseline. 4. From January 23, 2010 to October 5, 2011, the Veteran’s restrictive lung disease was manifested by shortness of breath and FEV-1 and FEV-1/FVC above 80 percent with no evidence of any inhalational or oral bronchodilator therapy. 5. The Veteran’s left ankle ligamentous laxity is proximately due to service-connected bilateral pes planus. 6. The Veteran’s right ankle peroneal ligamentous laxity is proximately due to service-connected bilateral pes planus.   CONCLUSIONS OF LAW 1. From January 23, 2010 to September 1, 2020, the criteria for a rating in excess of 10 percent for bilateral pes planus were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5276. 2. Since September 2, 2020, the criteria for a rating in excess of 30 percent for bilateral pes planus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5276. 3. The criteria for an initial rating in excess of 20 percent for bipolar disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Codes 9434-9432. 4. From January 23, 2010 to October 5, 2011, the criteria for a compensable rating for restrictive lung disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.96, 4.97, Diagnostic Code 6602. 5. The criteria for service connection for left ankle ligamentous laxity as secondary to service-connected bilateral pes planus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for right ankle peroneal ligamentous laxity as secondary to service-connected bilateral pes planus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from September 1997 to August 2000 with additional service in the Army Reserves and Army National Guard. This matter is before the Board of Veterans’ Appeals (Board) following a Board Remand in January 2020. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation 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. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection for pes planus. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial rating in excess of 10 percent from January 23, 2010 to September 1, 2020, for bilateral pes planus 2. Entitlement to a rating in excess of 30 percent since September 2, 2020, for bilateral pes planus The Veteran contends that she is entitled to higher ratings for her bilateral pes planus. The Veteran’s pes planus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The DC 5276 criteria are not conjunctive. The Court has indicated that § 4.21 applies are those in which the diagnostic criteria are not clearly joined in the conjunctive. Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007); see also Dyess v. Derwinski, 1 Vet. App. 448 (1991) (holding that 38 C.F.R. § 4.21 specifically applies to Diagnostic Code 5276). The Veteran underwent VA examination in April 2010 at which time the right foot showed a mild, right hallux valgus with 10 degrees of angulation (valgus), some diffuse bony tenderness along the forefoot, and a mildly abducted forefoot and mildly valgus hindfoot. There was loss of the normal, medial longitudinal arch. There were no callosities and no skin breakdown; vascular examination and foot temperature were normal. A comparison of the weightbearing and non-weightbearing alignment of the Achilles tendon was abnormal and could not be corrected by manipulation. There was pain on manipulation of the Achilles tendon. There was 10 degrees of valgus, not correctable by manipulation; and the forefoot and midfoot malalignment were not correctable by manipulation. There was no swelling, redness, heat or tenderness of the left foot. There was a mildly abducted forefoot and valgus hindfoot as well as a loss of the normal medial longitudinal arch of the left foot. There was abnormal alignment of the Achilles tendon when comparing weightbearing and non-weightbearing which could not be corrected by manipulation. There was 10 degrees of valgus, not correctable by manipulation; and the midfoot and forefoot malalignment were not able to be manipulated. The examiner diagnosed the Veteran as having mild pes planus of both feet with normal X-ray. The Veteran underwent VA examination on September 2, 2020, at which time the examiner noted that the Veteran had pain on manipulation and use accentuated, swelling on use, and calluses. There was not extreme tenderness of plantar surfaces. There was no marked deformity or pronation. There was no “inward” bowing of the Achilles tendon, marked inward displacement, or severe spasms of the Achilles tendon of either foot. Although the examiner noted that the Veteran’s pes planus required arch supports, custom orthotic inserts, or shoe modifications, she reported that none had ever been used. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for pes planus from January 23, 2010, to September 1, 2020. Although there was pain on manipulation and pain accentuated on use, there was no evidence of marked abduction, marked pronation, swelling, callosities, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. The Board also finds that the preponderance of the evidence is against a rating in excess of 30 percent for pes planus since September 2, 2020. Although there was pain on manipulation, pain accentuated on use, swelling, and callosities, there was no evidence of abduction, marked pronation, extreme tenderness of plantar surfaces of the feet, inward bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating severe unilateral or bilateral acquired flatfoot prior from January 23, 2010, to September 1, 2020 or more nearly approximating pronounced bilateral acquired flatfoot since September 2, 2020. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court’s holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court’s holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran’s disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to September 2, 2020, and in excess of 30 percent since September 2, 2020, for bilateral pes planus. 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 a rating in excess of 20 percent for bipolar disorder The Veteran contends that she is entitled to a higher rating for her bipolar disorder. In this case, service connection for bipolar disorder was established in a June 2013 rating decision on the basis that it was permanently worsened as a result of service-connected disabilities, migraines and musculoskeletal conditions. The current 20 percent rating assigned for bipolar disorder contemplated the difference between the baseline of disability and the effect of the service-connected disabilities. See 38 C.F.R. § 3.310(b). Specifically, the 20 percent rating assigned in the June 2013 rating decision was based on a finding that the criteria for a 70 percent rating was met and considering the pre-aggravation baseline of 50 percent, the 20 percent rating assigned reflected the aggravation. Id. An increase would be warranted only if the criteria for a 100 percent rating was met for anytime during the appeal period for the Veteran’s bipolar disorder and the pre-aggravation baseline is at 70 percent or below. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Initially, the Board notes that the pre-aggravation baseline of 50 percent rating assigned in the June 2013 rating decision was based in no small part on a January 2013 VA examiner’s assessment. The Agency of Original Jurisdiction (AOJ) found that prior to aggravation by a service connected condition, the disability was considered 50 percent disabling based on evidence that showed Global Assessment of Functioning (GAF) score during adolescence would have been in the 45-55 range due to depression, impulsive anger, violence, impairment in school due to grossly inappropriate behavior, suicidal gestures and in-patient hospitalizations. A Global Assessment of Functioning (GAF) score is a quantifiable assessment of overall functioning used by mental health clinicians that reflects an individual’s “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (both citing the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32 (1994)). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). The amendments replace those references with references to the recently updated DSM-5. As the Veteran’s claim was certified to the Board after August 4, 2014, the Board will use the DSM-5. See 79 Fed. Reg. 45,093-02 (August 4, 2014). As relevant to this case, the DSM-5 states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court’s holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores, however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board will afford the GAF scores mentioned in the record no probative value. See also Golden v. Shulkin, 29 Vet. App. 221 (2018) (Finding that the Board provided an inadequate statement of its reasons or bases for relying on GAF scores in its decision when the appeal was certified after August 4, 2014, and the DSM-5 applied to the claim). Thus, because the pre-aggravation baseline rating of 50 percent assigned in the June 2013 rating decision is at least partially based on GAF scores, the Board must assign a pre-aggravation rating based solely on the Veteran’s bipolar disorder symptoms prior to aggravation. The Veteran underwent VA examination in April 2010 at which time she could not recall her educational history but noted that she did not fit in, that the other students taunted her, and that she got back at those people. She stated that she had had interventions from the police after she had “one of many fights.” The examiner noted, This is a veteran who has had longstanding personality disorder, difficulties and longstanding issues with regard to potential psychotic symptoms of delusions related to the history that was given in regard to her childhood as well as her family being cursed. … In assessing risks for self harm, the self cutting that she has done is related to her personality disorder as there are no indications with the depression and her bipolar 2 disorder that at times of worsening of the mood disorder that she becomes more self mutilating. The Veteran underwent VA examination in January 2013. In an April 2013 addendum, the VA examiner who conducted a January 2013 examination stated, Veteran has suffered with a bipolar affective disorder (Bipolar II) since childhood. … According to veteran’s self report alone provided on three C&P exams regarding her pre-military history it appears that her Bipolar II Disorder has always been severe, particularly the hypomanic episodes which were usually expressed with impulsive anger. She reports that she was also always unhappy as a child. Veteran’s baseline therefore, has always been low … due to the violence, impairment in school due to grossly inappropriate behavior, self mutilation/injury, suicidal gestures and in-patient hospitalizations. The Veteran also underwent VA examination in September 2020. In an addendum later that month, the VA examiner who conducted a September 2020 examination stated, The veteran’s medical records contain substantial documentation of grossly inappropriate behavior since childhood. Documented is that her behavior escalated in aggression and in 3rd grade …. By her high school years her aggression and sadistic tendencies escalated …. Her aggression was also sometimes targeted at herself as she cut herself, for which when she was in high school she was hospitalized for 6 months. … The records document the veteran’s behavioral outbursts and anger have always been severe since then, therefore it is estimated that this has been the veteran’s approximate baseline for the years following high school as well. The Board notes that in addition to bipolar disorder, the Veteran has also been diagnosed as having posttraumatic stress disorder (PTSD), depression/depressive disorder, alcohol dependence, and borderline personality disorder. Although the April 2010 VA examiner opined that the Veteran’s self-mutilation was related to her personality disorder, the January 2013 and September 2020 VA examiner found that it was not possible to differentiate what symptoms were attributable to each diagnosis. In this case, the VA examiners’ findings in April 2010, April 2013, and September 2020 indicate that the Veteran’s bipolar disorder prior to aggravation was manifested by symptoms associated with a 100 percent rating; specifically, grossly inappropriate behavior and persistent danger of hurting self or others. As the most probative evidence of record shows total occupational and social impairment prior to aggravation, the Board finds that the maximum 100 percent rating is assigned as baseline. Thus, even for the sake of argument that the Veteran’s bipolar disorder symptoms since January 23, 2010, could be assigned a 100 percent rating, the severity of the disability is considered unchanged. In other words, the baseline level of severity deducted from the current level of severity would equal zero. As such, the preponderance of the evidence is against a rating in excess of 20 percent for bipolar disorder, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to an initial compensable rating from January 23, 2010 to October 5, 2011, for restrictive lung disease The Veteran contends that she is entitled to a compensable rating for her restrictive lung disease prior to October 6, 2011. Prior to October 6, 2011, the Veteran’s restrictive lung disease was rated pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6602. Under Diagnostic Code 6602, a 10 percent rating is warranted for an FEV-1 of 71 to 80 percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy. 38 C.F.R. § 4.97, Diagnostic Code 6602. Post-bronchodilator results are required when pulmonary function tests (PFT) are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. See 38 C.F.R. § 4.96 (d)(4). In applying the rating criteria, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case the pre-bronchodilator values should be used for rating purposes. 38 C.F.R. § 4.96 (d)(5). The Veteran underwent VA examination in April 2010 at which time she reported shortness of breath after walking up a few stairs. She also reported that she occasionally used her child’s nebulizer with some relief. She denied a history of wheezing and denied been diagnosed with asthma or chronic obstructive pulmonary disease or emphysema. PFT results were FEV-1 85% predicted, FEV-1/FVC 112%. There was no response to bronchodilation. The Veteran was noted to have mild restrictive disease. Here, the Veteran’s PFT testing results do not warrant a compensable rating. In order to warrant a 10 percent rating, FEV-1 or FEV-1/FVC test results must be under 80 percent. The Veteran’s results for were above 80 percent, resulting in a noncompensable rating. Further, there is no evidence showing any inhalational or oral bronchodilator therapy. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 5. Entitlement to service connection for left ankle ligamentous laxity 6. Entitlement to service connection for right ankle peroneal ligamentous laxity The Veteran contends that her ankle disorders had their onset during service. In September 2006, the Veteran stated that her ankle pain was due to a car accident while on a mission. Service treatment records indicate that in November 1997, the Veteran was seen for ankle pain for two weeks. On Report of Medical Examination in December 2005, while serving with the Army National Guard, bilateral ankle weakness was noted as well as reoccurring sprains. The Veteran underwent VA examination in April 2002 at which time she reported a six-year history of bilateral ankle pain and weakness with increased ankle laxity and a tendency to strain and twist the ankles on uneven terrain. The Veteran stated that the ankle condition was improved whenever she wore boots due to the ankle support but that whenever she wore regular shoes, she noticed an increased tendency to sprain her ankles. After physical examination, the Veteran was diagnosed as having bilateral ankle laxity. The Veteran underwent VA ankle conditions examination in September 2020 at which time she was diagnosed as having bilateral ankle arthritis. The examiner opined that the Veteran’s ankle arthritis was directly caused by her pes planus. The examiner noted that the Veteran had no issues related to the claimed bilateral ankle disability prior to military service, that wear and tear could weaken the tendon that runs along the inside of the ankle which helps support the arch, and that over time fallen arches could lead to osteoarthritis of the ankles. The examiner noted that es planus, or fallen arches, were risk factors for the development of ankle arthritis. The examiner noted that risk factors for the development of ankle arthritis include bone or ligament deformities, repeated stress on the joint, and joint injuries. Mayo Foundation for Medical Education and Research. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current ankle disabilities are proximately due to service-connected pes planus. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection is warranted for left ankle ligamentous laxity and right ankle peroneal ligamentous laxity. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a rating in excess of 30 percent since October 6, 2011 for restrictive lung disease In January 2020, the Board noted that PFT results in 2012 were not of record and directed that outstanding pulmonary records be obtained. The actual PFTs are still not of record. A VA respiratory therapy/pulmonary diagnostics study report dated August 17, 2012, indicates that PFT data could be viewed in Vista. The Veteran underwent VA respiratory conditions examination in September 2020; however, PFTs were not conducted due to limitations related to the COVID-19 pandemic. The Board understands the difficulties involved in conducting PFT during the COVID-19 pandemic. The Veteran, however, has a right to undergo a complete and adequate VA examination, and the Board finds such updated evidence would be useful in adjudicating the rating issue on appeal. Accordingly, the Board finds that the appropriate course of action is to remand for a VA examination that includes PFT. Hopefully, by the time such an examination is scheduled, the conditions will be in place for the Veteran to safely undergo PFT. A June 2013 rating decision increased the rating for the Veteran’s restrictive lung disease from 10 percent to 30 percent effective from October 6, 2011. An October 2018 rating decision granted service connection for sleep fragmentation to include snoring claimed as obstructive sleep apnea (OSA) and assigned a 30 percent rating effective from November 10, 2017; the issue was then combined with the restrictive lung disease. Rating co-existing respiratory conditions is governed by 38 C.F.R. § 4.96 (a), which states that ratings under diagnostic codes 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, ratings under diagnostic codes 6819 and 6820 will not be combined with each other or with diagnostic codes 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. Accordingly, separate ratings for asthma under Diagnostic Code 6602 and sleep apnea under Diagnostic Code 6847 are not permitted. In this case, separate ratings are prohibited by 38 C.F.R. § 4.96 (a) as both asthma and OSA are both manifested by lung or pleural involvement. As such, the Board must consider which diagnostic code is more appropriate throughout the appeal period. The Board, therefore, finds that an examination is also necessary to address the current severity of the Veteran’s sleep fragmentation to include snoring. In addition, the record indicates that the Veteran has a follow up for sleep study in April 2021. All current VA treatment records from April 1, 2021 should be associated with the file. 2. Entitlement to service connection for a gastroesophageal disability, to include GERD 3. Entitlement to service connection for an intestinal disability, to include IBS The Veteran’s service treatment records include an August 1997 Report of Medical Examination which evaluated the Veteran’s abdomen and viscera as normal. On the Report of Medical History completed by the Veteran in conjunction with her August 1997 physical, she denied ever having frequent indigestion, stomach trouble, and intestinal trouble. She did, however, note that she had been seen around March 1996 with stomach inflammation but had had no problems since that time. In addition to stomach issues of nausea and vomiting related to migraine headaches or pregnancy, the Veteran had numerous in-service stomach complaints including nausea, vomiting, and abdominal pain and a diagnosis of viral gastroenteritis. VA obtained a medical opinion in June 2010 as to the nature and etiology of the Veteran’s gastrointestinal disorders. The examiner stated that the Veteran had a pre-service treatment and hospitalization for stomach inflammation as shown on military entrance exam in August 1997. The examiner opined that it was not at least as likely as not that the preexisting stomach/GI condition was permanently aggravated by service beyond its normal progression. The examiner noted that the Veteran’s inservice treatment on several occasions for complaints of diarrhea and viral gastroenteritis was not a permanent worsening, but simply a normal progression of the preexisting condition. In January 2020, the Board found that the June 2010 opinion was inadequate for as the examiner did not provide a rationale to support his position and directed that an additional medical opinion be obtained. VA obtained a medical opinion in July 2020 at which time the examiner stated, “There are no records available. There is no DD 214 to establish dates of service. There is only a GYN DBQ available and no documentation to support dyspnea. No STR’s or records proximate to service are available.” The examiner opined that the Veteran’s gastrointestinal disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness but noted, “In the absence of available medical records or DBQ, no opinion can be rendered. Furthermore, there is no specific condition claimed.” In November 2020, VA obtained an addendum opinion from the July 2020 VA examiner as to the nature and etiology of the Veteran’s gastrointestinal disability. The examiner opined that the Veteran’s GERD was less likely than not pre-existed service and was less likely than not (a 50% or lesser probability) that any identified gastrointestinal disorder is related to her active duty service. VA treatment records indicate that the Veteran has constipation related to iron therapy used to treat her anemia. The Board notes again that in a November 2016 gastroenterology consultation note, the provider found that the Veteran’s “chronic issues with constipation” was aggravated by prenatal vitamins and ferrous sulfate that the Veteran took for anemia. As the Veteran is service-connected for microcytic anemia, an opinion should be obtained to determine whether any of the Veteran’s gastrointestinal conditions are proximately caused or aggravated by any medication that the Veteran takes for service-connected disabilities. The Board, therefore, finds that an additional medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain any of the Veteran’s VA treatment records for the period starting April 1, 2021. Additionally, obtain outstanding VA pulmonary function test (PFT) results in the Computerized Patient Record System (CPRS) Tools/Vista Imaging, including PFTs conducted in August 2012. If no such records are located, that fact must be clearly documented in file. (Continued on the next page)   2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected respiratory disability and sleep fragmentation to include snoring claimed as OSA. The examiner is to provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s disabilities under the rating criteria. The examination is to include pulmonary function testing (PFT). 3. Obtain a medical opinion by an appropriate clinician to address whether any currently diagnosed gastrointestinal disorder was caused by or has been aggravated by the Veteran’s service-connected disabilities to include effects from medications taken for such service-connected disabilities. Aggravation is defined as any increase in disability. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. Emily Tamlyn Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Olson, Patricia 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.