Citation Nr: 21030898 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-09 542 DATE: May 19, 2021 REMANDED Entitlement to a compensable evaluation for restless leg syndrome, for the period prior to October 4, 2018, is remanded. Entitlement to an evaluation in excess of 40 percent, for radiculopathy and restless leg syndrome, left lower extremity, for the period beginning October 4, 2018, is remanded. Entitlement to an evaluation in excess of 40 percent, for radiculopathy and restless leg syndrome, right lower extremity, for the period beginning October 4, 2018, is remanded. Entitlement to an initial evaluation in excess of 20 percent for hemorrhoids is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1979 to November 2003. The claims of entitlement to a higher evaluation for restless leg syndrome and hemorrhoids were previously before the Board in July 2018 when they were remanded for additional development. In addition, the Board remanded the issue of entitlement to service connection for diabetes mellitus, type II. In an April 2020 rating decision, entitlement to service connection for diabetes mellitus, type II, was granted. As this decision represents complete grant of the benefit sought on appeal with regard to diabetes mellitus, the issue is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). In a January 2019 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection and assigned separate ratings for radiculopathy of the left and right lower extremities, as secondary to the service-connected back disability. The AOJ assigned 40 percent ratings for each sciatic nerve and 30 percent ratings for each femoral nerve; all effective October 4, 2018. The AOJ referred to the October 4, 2018 effective date as a date of claim. In a September 2020 rating decision, the AOJ included the evaluation of restless leg syndrome for each leg with the previously assigned evaluation for the lower extremity radiculopathy for each leg, and continued the 40 percent rating, effective October 4, 2018. Therefore, the Board has recharacterized the issue regarding a higher evaluation for restless leg syndrome as the issues listed above. 1. Entitlement to a compensable evaluation for restless leg syndrome, for the period prior to October 4, 2018, is remanded. 2. Entitlement to an evaluation in excess of 40 percent, for radiculopathy and restless leg syndrome, left lower extremity, for the period beginning October 4, 2018, is remanded. 3. Entitlement to an evaluation in excess of 40 percent, for radiculopathy and restless leg syndrome, right lower extremity, for the period beginning October 4, 2018, is remanded. The procedural history related to the ratings for the lower extremity nerve impairment is complicated and the reasoning for the change in ratings and the effective date used must be clarified on remand. The January 2019 rating decision resulted in 2 separate ratings for each lower extremity. The September 2020 rating decision "closed out" the separate ratings for the femoral nerve impairment and included the restless leg syndrome which the AOJ referred to as "previously evaluated separately." As a result, there was only 1 rating for each lower extremity. The claim of service connection for restless leg syndrome has been pending before the October 2018 effective date assigned by the AOJ. Further, the January 2019 rating decision did not include any discussion of "restless leg syndrome." On remand, the AOJ must determine whether a separate rating is warranted for restless leg syndrome prior to October 2018 and clarify the specific rating criteria assigned. The claim is also remanded to obtain additional treatment records. VA treatment records show that the Veteran has received non-VA physical therapy, aquatherapy, and chiropractic treatment. Records regarding this treatment have been scanned into VISTA Imaging; however, they are not associated with the record before the Board. See, e.g., VA Treatment July 2019, January 2021. Records related to treatment with Community Care acupuncture must also be obtained. See VA Treatment October 2020. In addition, treatment records from other private providers must be obtained. The Veteran has been continually prescribed Clonazepam for restless leg syndrome by an outside provider. See, e.g., VA Treatment, February 2018. He has also been treated an outside cardiologist and urologist. See, e.g., VA Treatment December 2020. 4. Entitlement to an initial evaluation in excess of 20 percent for hemorrhoids is remanded. The Veteran seeks a rating in excess of 20 percent for his service-connected hemorrhoid disability. 20 percent is the maximum rating available for a hemorrhoid disability under Diagnostic Code 7336. Pursuant to the prior Board remand, the Veteran was afforded VA examinations in June 2019 and November 2020. However, the medical examinations are not consistent and are inadequate because they are unclear as to which findings are manifestations of the service-connected hemorrhoid disability. In June 2019 the Veteran was diagnosed with internal and external hemorrhoids as well as pruritis ani and anal fissure, which the examiner said were a progression of the hemorrhoid condition. Thereafter, in November 2020 the Veteran was only diagnosed with internal or external hemorrhoids; however, the examiner identified symptoms including internal or external hemorrhoids as well as impairment of rectal sphincter of moderate leakage. The examiner concluded that there was a worsening of the Veteran's symptoms but no change in the service-connected diagnosis and no additional diagnoses. However, the examiner identified that the Veteran had periodic leakage with abdominal pressure. It is notable that there is no discussion of any significance of the Veteran's September 2020 diagnostic colonoscopy, performed to find an explanation of the Veteran's loose stools and weight loss, that found internal and external hemorrhoids. The June 2019 examiner said pruritis ani and anal fissure were a progression of the hemorrhoid condition. The November 2020 examiner did not identify any diagnoses other than hemorrhoids, including pruritis ani, but indicated that the Veteran had impairment of the rectal sphincter with moderate leakage. The matters are REMANDED for the following action: 1. Ask the Veteran to complete VA Form 21-4142s identifying his private providers, including the provider who prescribed Clonazepam for restless leg syndrome, his private cardiologist and urologist, and the provider of his acupuncture treatment. Make two requests for the authorized records from all identified private providers, unless it is clear after the first request that a second request would be futile. 2. Obtain and associate with the claims file all treatment records scanned into VISTA Imaging. 3. Obtain the Veteran's VA treatment records for the period from January 2021 to the present. 4. Thereafter, schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the severity of his service-connected lower extremity radiculopathies. Copies of all pertinent records should be forwarded to the examiner for review. The appropriate Disability Benefits Questionnaires (DBQs) should be filled out for this purpose, if possible. The examiner must specifically identify whether the Veteran had a disability affecting either leg characterized by "restless leg syndrome" for the period before October 4, 2018. 5. After the completion of step one schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) by an appropriate clinician to determine the current severity of his service-connected hemorrhoid disability. 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, to include all manifestations of the Veteran's hemorrhoid disability. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner must specifically address all manifestations of the Veteran's service-connected hemorrhoid disability to include whether that includes fecal leakage. The examiner must comment on the findings of the prior VA examinations, the treatment records, and the findings of the September 2020 colonoscopy. To the extent possible, the examiner should identify any symptoms and functional impairments and discuss the effect of the Veteran's hemorrhoid disability on any occupational functioning and activities of daily living. The examiner must provide a rationale for any opinion expressed. 6. After the completion of the above, if appropriate, refer the Veteran's claim for an increased rating for service-connected hemorrhoids to VA's Director of Compensation Service for extraschedular consideration. 7. Clarify the specific rating criteria and rationale used in the January 2019 and September 2020 rating decisions that assigned separate ratings then discontinued two of the ratings for the lower extremity nerve impairment. The M.E. LARKIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.