Citation Nr: 21030344 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 10-35 157 DATE: May 18, 2021 ORDER Entitlement to a rating in excess of 10 percent for low back disability prior to May 15, 2019, and in excess of 20 percent thereafter, is denied. REMANDED Entitlement to service connection for a prostate condition is remanded. Entitlement to service connection for hypothyroidism, to include as due to exposure to environmental hazards during Gulf War service, is remanded. Entitlement to a compensable rating for a hemorrhoid disability prior to June 15, 2010, and in excess of 10 percent thereafter, is remanded. FINDINGS OF FACT 1. Prior to May 15, 2019, the most probative evidence of record reflects, the Veteran's service-connected low back disability was manifested by pain productive of limitation of forward flexion of the lumbar spine, at worst, to 70 degrees and combined range of motion of 210 degrees. 2. From May 15, 2019, the most probative evidence of record reflects, the Veteran's service-connected low back disability was manifested by pain productive of limitation of forward flexion of the lumbar spine, at worst, to 40 degrees. 3. Ankylosis of the lumbar spine was not shown by the evidence of record at any point on appeal. CONCLUSIONS OF LAW 1. Prior to May 15, 2019, a rating in excess of 10 percent for low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Code (DC) 5243. 2. From May 15, 2019, a rating in excess of 20 percent for low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, DC 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1974 to August 1983 and from June 1984 to May 1995. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In December 2017, the Board remanded the issues currently on appeal for additional development. A claim for service connection for sleep apnea was also developed for appellate consideration. During the pendency of the remand development, a June 2019 rating decision granted entitlement to service connection for sleep apnea. The grant of service connection for sleep apnea was a full grant of the benefit sought and will not be addressed further herein. See AB v. Brown, 6 Vet. App. 35 (1993). Also during the pendency of the remand development, a June 2019 rating decision granted an increased evaluation of 20 percent for the low back disability, effective May 15, 2019. As this partial rating increase is not the maximum allowable for the entire period on appeal, this issue remains on appeal. See id. The Board notes that in his December 2008 claim, the Veteran had requested, in relevant part, entitlement to service connection for a prostate condition. See December 2008 VA 21-4138 Statement in Support of Claim. As noted below, the Veteran has since been diagnosed with enlarged prostate, benign prostatic hyperplasia (BPH), and prostate adenocarcinoma (prostate cancer) during the relevant period on appeal. Although the RO has characterized the claim as mild enlargement of the prostate, the Board will broadly construe the claim for service connection for any diagnosed prostate condition, to include enlarged prostate, BPH, and prostate cancer as well. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the Board must consider any disability that "may reasonably be encompassed by" the description of the claim and symptoms or other submitted information.). The Board notes that a remand has been determined as warranted, in part, to obtain outstanding treatment records pertinent to the remanded issues detailed below. However, the Board notes that the Veteran has specifically identified such records as pertinent to the appealed issues of his prostate condition and his hypothyroidism. See March 2018 VA 21-4138 Statement in Support of Claim. Although the Veteran has identified orthopedic records as well, he has specified that such records are related to his prior appeals for his knees, that are no longer before the Board. See id. As such records have been noted as not relevant to the issue of the low back increased rating claim, the Board may proceed with the appeal for this particular issue. Increased Rating Disability ratings are determined by applying the criteria set forth in 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. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). Entitlement to a rating in excess of 10 percent prior to May 15, 2019, and in excess of 20 percent thereafter, for low back disability. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a. The Board notes that 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 select 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 also 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. The criteria that is more favorable to the Veteran will be applied. Prior to February 7, 2021, the General Rating Formula for Diseases or Injuries of the Spine pertained to diagnostic codes 5235 to 5243. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine. Under this rating criteria, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a 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 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 rating is warranted for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral extension are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (2). Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (5). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent rating is assigned where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 20 percent rating is assigned where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 10 percent rating is assigned where there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a; Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). Effective February 7, 2021, DC 5242, applies to degenerative arthritis and DDD other than IVDS. DC 5243 applies to IVDS and directs the rater to assign that diagnostic code only when there is disc herniation with compression of the adjacent nerve root, and to assign DC 5242 for all other disc diagnoses. However, throughout the period on appeal, as noted more fully below, the Veteran's lumbar spine disability has not been shown to be manifested by IVDS with incapacitating episodes having a total duration to warrant a rating greater than the evaluations currently assigned. Accordingly, the rating criteria pertaining to the Veteran's service-connected lumbar spine disability has not substantially changed as a result of the February 7, 2021 amendments. After a review of the evidence of record, the Board finds that throughout the period on appeal, a rating in excess of 10 percent disabling prior to May 15, 2019, and in excess of 20 percent thereafter for the service-connected low back disability is not warranted. Factual Background In a January 2009 VA examination, the Veteran reported intermittent low back pain localized in the low back area without radiation of symptoms. See January 2009 VA Examination. The Veteran denied a history of hospitalization or surgery, denied any associated neurological disabilities. The Veteran reported that during flareups, he was unable to perform heavy lifting or forceful movements. He reported being able to walk one to three miles, had orthotic inserts, and used a soft lumbosacral corset. No incapacitating episodes were noted. On physical examination, the examiner noted the Veteran had normal posture, normal head position, symmetry in appearance, and normal gait. No abnormal spinal curvatures were noted, to include lordosis. Although muscle spasm was noted on the left and right, the examiner noted the lumbar spasm was not severe enough to cause abnormal gait or abnormal spinal contour. The examiner also noted x-rays of the spine in April 2000 that revealed straightening of the normal lordosis and that the straightening was related to muscle spasm. Muscle tone was normal with no muscle atrophy, motor, sensory, and reflex examination were normal, and Lasègue's sign was not positive. On range of motion testing, flexion was to 90 degrees with no pain on active or passive motion, no pain after repetitive use, and no additional loss of motion on repetitive use; extension was to 20 degrees with pain beginning at 20 degrees, no pain was noted on active or passive motion but there was pain after repetitive use and additional loss of motion of 20 to 30 degrees. Lateral flexion and rotation on the right and left were all to 30 degrees with no pain on active or passive motion, no pain after repetitive use, and no additional loss of motion on repetitive use. Resisted isometric movement was noted as normal. The examiner noted no significant effects on usual occupation. Regarding usual daily activities, the examiner noted moderate effects on exercise and dressing, and mild effects on sports and recreation. The examiner diagnosed lumbar fibromyositis. VA treatment records from April 2009 to March 2010 noted that his musculoskeletal system's range of motion was intact, had adequate muscle tone, and had no deformities. These records also noted neurologically, there were no gross motor and sensory deficit noted. See July 2010 CAPRI. In a June 2010 VA examination, the Veteran reported having difficulty doing heavy lifting during flare-ups. See June 2010 VA Examination. The Veteran denied a history of hospitalization or surgery, denied any associated neurological disabilities. The Veteran reported intermittent radiating pain to the right lower extremity. No incapacitating episodes were noted. The Veteran reported being able to walk more than a quarter mile but less than a mile. He denied the use of devices or aids. On physical examination, the examiner noted the Veteran had normal posture, normal head position, symmetry in appearance, and normal gait. No abnormal spinal curvatures were noted, to include lordosis. The examiner noted that although localized tenderness, muscle spasm, and guarding were noted, they were not severe enough to cause abnormal gait or abnormal spinal contour. The examiner also noted x-rays of the spine in April 2000 that revealed straightening of the normal lordosis and that the straightening was related to muscle spasm. Muscle tone was normal with no muscle atrophy, motor, sensory, and reflex examination were normal, and Lasègue's sign was not positive. On range of motion testing, flexion was to 70 degrees, extension to 25 degrees, and left and right lateral rotation and flexion were all to 30 degrees. The examiner noted there was pain on active range of motion and objective evidence of pain following repetitive motion, but there were no additional limitations of range of motion after three repetitions noted. The examiner noted no significant effects on usual occupation. Regarding usual daily activities, the Veteran reported difficulty dressing his lower extremities. The examiner diagnosed lumbar fibromyositis and lumbar spondylosis and discogenic disease L5 to S1. A November 2010 VA examination noted the Veteran's service-connected low back condition had not changed since the last examination in June 2010. See November 2010 VA Examination. VA treatment records from April 2011 to January 2017 noted that his musculoskeletal system's range of motion was intact, had adequate muscle tone, and had no deformities. These records also noted neurologically, there were no gross motor and sensory deficit noted. See May 2011 CAPRI, September 2014 CAPRI, and May 2020 CAPRI. VA treatment records from July 2013 to May 2018 also noted the Veteran's musculoskeletal system had no deformity, had full range of motion, and had no tender joints. These records also noted neurologically, there were no gross motor and sensory deficit noted. See September 2014 CAPRI and May 2020 CAPRI. In a May 2019 VA examination, the Veteran reported severe low back pain and that he had difficulty bending over. See May 2019 C&P Exam. On range of motion testing, flexion was to 50 degrees, extension was to 20 degrees, and right and left lateral flexion and rotation were all to 20 degrees. There was evidence of pain with weight bearing and non-weight bearing, pain on passive range of motion testing, and objective evidence of localized tenderness or pain on palpation noted. The Veteran was able to perform repetitive use testing with at least three repetitions but there was no additional loss of function or range of motion after three repetitions. Due to pain, repeated use over a period of time as well as during flare-ups, forward flexion was limited to 40 degrees, extension was limited to 10 degrees, and right and left lateral flexion and rotation were all limited to 10 degrees. The examiner noted lumbar spasms that did not result in abnormal gait or abnormal spinal contour. Muscle strength testing was normal, no muscle atrophy was noted, and sensory and reflex examination were normal. Straight leg raising test on the right and left were negative, no radicular pain or signs or symptoms due to radiculopathy was noted. No ankylosis was noted and no other neurologic abnormalities were noted. The examiner noted the Veteran had IVDS of the spine but only had episodes of bedrest with a total duration of at least one week but less than two weeks in the past 12 months. The Veteran had reported that in February 2019, he had pain that was a 10 out of 10 and was injected with Toradol with lidocaine and recommended to rest for some days by the treating provider. The Veteran reported the occasional use of a one point cane for his low back condition. No other pertinent physical findings, complications, conditions, signs, symptoms, or scars were noted. The examiner noted the Veteran's low back disability did not impact his ability to work and diagnosed lumbar spondylosis and discogenic disease L5 to S1. Analysis Based on the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted prior to May 15, 2019. In this regard, forward flexion and combined range of motion were measured, at worst, at 70 degrees and 210 degrees, respectively. The Board notes that the combined range of motion of 210 degrees was based on the January 2009 VA examination's finding that there was an additional loss of motion of 20 to 30 degrees for extension after repetitive use. The evidence of record during this period on appeal has not otherwise noted additional limitation of range of motion following pain or repetitive use to warrant a rating greater than 10 percent. No findings of ankylosis was noted either. The Board acknowledges the January 2009 and June 2010 VA examiners' reference to an April 2000 x-ray of the spine that showed straightening of the normal lordosis and that the straightening was related to muscle spasm. However, the Board highlights this April 2000 record was during a period not considered on appeal, almost a decade prior to the effective date of the service connection. Additionally, both the January 2009 and June 2010 VA examiners specifically found there was no abnormal spinal contour, to include lordosis or kyphosis, due to the Veteran's muscle spasms on physical examination. Moreover, VA treatment records have consistently noted the Veteran's musculoskeletal system did not have deformities. Even during the May 2019 VA examination that showed worsening of the low back condition, the examiner found that the Veteran's lumbar spasms did not result in abnormal spinal contour. Ultimately, the Board finds the VA examiners' specific findings that there was no abnormal spinal contour due to muscle spasms, in conjunction with the VA treatment records consistently noting no deformities in the musculoskeletal system, as indicative of the actual severity of the Veteran's spasms for the considered period on appeal, from December 29, 2008. Although there is evidence that the Veteran may have had IVDS sometime in February 2019, an increased disability rating is not warranted under the IVDS Formula because the Veteran has not had incapacitating episodes having a total duration of at least two weeks but less than four weeks during this initial period on appeal to warrant the next higher rating of 20 percent under DC 5243. The Veteran does not contend otherwise. From May 15, 2019, the evidence of record does not reflect limitation of forward flexion of the thoracolumbar spine to 30 degrees or less, or unfavorable ankylosis, to warrant a rating in excess of 20 percent. Rather, the evidence of record demonstrates range of motion limited to, at worst, 40 degrees of forward flexion, even after considering additional limitation of range of motion during flare-ups or after repetitive use of the spine. Accordingly, an evaluation in excess of 20 percent is not warranted. An increased disability rating is also not warranted under the IVDS Formula because the Veteran has not had incapacitating episodes with prescribed bed rest by a physician for a total duration of at least four weeks but less than six weeks during the past 12 months. The Veteran does not contend otherwise. In addition to considering the orthopedic manifestations of a low back disability, VA regulations also require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. While the Veteran reported subjective symptoms of radiating pain into the right lower extremity during the June 2010 VA examination, physical examinations of the lower extremities have consistently failed to show any objective findings consistent with neuropathy. VA treatment records have also consistently noted that neurologically, there were no gross motor and sensory deficit noted throughout the period on appeal. Additionally, the Veteran has not alleged, and the evidence does not show, that he has bladder impairment, bowel impairment as a result of his service-connected low back disability, and the VA examiners specifically found no neurologic impairment associated with the low back disability. For this reason, separate ratings for objective neurological abnormalities were not warranted at any time during the period on appeal. Based on the foregoing, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent prior to May 15, 2019, and in excess of 20 percent thereafter for low back disability. In reaching this decision the Board considered the doctrine of reasonable doubt, however, to the extent the preponderance of the evidence is against ratings higher than or separate from that already assigned for low back disability, the doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND Entitlement to service connection for a prostate condition is remanded. The Veteran contends that he has a prostate condition that is related to his elevated prostate specific antigen (PSA) noted in his service treatment records during his active service. See March 2018 VA 21-4138 Statement in Support of Claim. A review of the record shows that the Veteran has a diagnosis of BPH for his enlarged prostate that may be related to his elevated PSA. Specifically, a May 2019 VA treatment record noted the Veteran's BPH status post transurethral resection of the prostate (TURP) and repeat urine specimen collections showing elevated PSA associated with the BPH condition throughout the period on appeal. See May 2020 CAPRI. A review of the service treatment records (STRs) confirm the Veteran's reports of elevated PSA in January 1995 and February 1995. See July 2016 STR Medical. Furthermore, a March 1996 VA general medical examination, conducted less than a year after the Veteran separated from active service, noted that a rectal examination of the Veteran revealed slight enlarged prostate gland. See March 1996 VA Examination. The Veteran has also been diagnosed with prostate cancer in December 2019. See id. The Veteran has not yet been afforded a VA examination or medical opinion in relation to his claimed prostate condition. VA will provide a medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing that certain diseases manifested during an applicable presumptive period for which the veteran qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability; but insufficient competent medical evidence on file for VA to make a decision on the claim. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In this case, the Board finds that the low threshold for provision of a VA examination described in McLendon has been met. Therefore, the Veteran must be provided a VA examination to determine the nature and likely etiology of his prostate condition. The Veteran also identified outstanding private treatment records related to his prostate condition. See March 2018 VA 21-4138 Statement in Support of Claim. On remand, such records should be obtained. Entitlement to service connection for hypothyroidism, to include as due to exposure to environmental hazards during Gulf War service is remanded. A review of the record shows that there are outstanding pertinent treatment records related to the Veteran's diagnosed hypothyroidism that should be obtained on remanded. Specifically, the Veteran has reported treatment for his hypothyroidism by a private endocrinologist for about 15 years. See March 2018 VA 21-4138 Statement in Support of Claim. VA treatment records from 2007 to 2020 also consistently note the Veteran was receiving treatment by his private endocrinologist for his hypothyroidism. See May 2010 CAPRI. However, a review of the record does not show that any such records have been obtained. Thus, a remand is warranted to obtain these treatment records. Additionally, the Veteran contends that his diagnosed hypothyroidism is related to his conceded exposure to environment hazards during his verified Gulf War service. See August 2010 Form 9, September 2014 C&P Exam, and July 2016 Military Personnel Record. The Veteran has not been provided a VA examination for his hypothyroidism. Thus, on remand, a VA examination and etiological opinion for this condition should be obtained as well. Entitlement to a compensable rating prior to June 15, 2010, and in excess of 10 percent thereafter, for hemorrhoid disability is remanded. Preliminarily, the Board notes that the Veteran did not include the issue of an increased rating for his service-connected hemorrhoid disability in his August 2010 substantive appeal. See August 2010 Form 9. Additionally, the Veteran's representative had sent a correspondence confirming the issues appealed in August 2010 that also did not include the issue of an increased rating for the service-connected hemorrhoid disability. See August 2010 Third Party Correspondence. However, in light of the June 2016 certification of the issue to the Board, the July 2017 appellate brief's inclusion the issue, the prior Board remand considered and remanded the issue for further development, the August 2020 supplemental statement of the case (SSOC) addressed the issue, and the March 2021 appellate brief included the issue, the Board accepts jurisdiction over the issue of increased rating for the hemorrhoid disability. See Percy v. Shinseki, 23 Vet. App. 37, 46-7 (2009) (by treating an issue as in appellate status for an extended period, VA waives any objections it might have had to exercising jurisdiction). The Board notes that the Veteran was last provided a VA examination related to his service-connected hemorrhoid disability in June 2010. See June 2010 VA Examination. During examination, the Veteran reported small amount of bleeding once or twice monthly. The examiner also noted that there was no evidence of bleeding at the time of examination. However, the evidence of record indicates that the Veteran's hemorrhoids may have worsened in severity since the 2010 VA examination. Specifically, November 2018 VA treatment records noted the Veteran's reports of active rectal bleeding secondary to his hemorrhoids for several days and also the Veteran's low hemoglobin/hematocrit after hemorrhoidal bleed of which he was consequently prescribed iron supplements for the bleeding. See May 2020 CAPRI. Thus, a remand is warranted to obtain a VA examination to determine the current severity of the Veteran's service-connected hemorrhoid disability. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain all outstanding VA and private treatment records, to include his private treating providers in Puerto Rico, to include but not limited to, Dr. Velazquez, Dr. Renjifo, Dr. Colon Rivera, and Dr. Ambert. 2. After development #1 has been completed, schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of his prostate condition. Provide a copy of this remand and the record for the examiner to review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After a review of the claims file, the examiner must address the following: (a) Identify all diagnosed prostate conditions since the date of the claim (i.e. December 2008), to include enlarged prostate, BPH, and prostate cancer. (b) Determine whether it is at least as likely as not (50 percent probability or greater) that any diagnosed prostate condition had its onset during active service, or is otherwise etiologically related to his periods of service? Explain why or why not. The examiner should address the January 1995 and February 1995 STRs showing elevated PSA levels, the March 1996 general medical examination revealing slightly enlarged prostate gland, and the VA treatment records suggesting a link between the Veteran's elevated PSA and BPH. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed must be provided as the Board is precluded from making any medical findings. 3. Than schedule the Veteran for a VA examination with an appropriate clinician to determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's currently diagnosed hypothyroidism is related to his periods of service, to include environmental hazard exposures due to service in the Gulf War. After a review of the claims file, the examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed must be provided as the Board is precluded from making any medical findings. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hemorrhoids. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Cheng, 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.