Citation Nr: 21041010 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 16-24 988 DATE: July 7, 2021 ORDER From January 1, 2016 to June 3, 2016, a 60 percent rating for right knee, status post total arthroplasty, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 60 percent for right knee, status post total arthroplasty, is denied. Entitlement to a separate 10 percent rating for right knee slight lateral instability from January 1, 2016 to the present, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease associated with right knee status post total arthroplasty, is denied. Effective March 22, 2016, entitlement to a separate 10 percent rating for left knee slight lateral instability, is granted, subject to the laws and regulations governing the payment of monetary benefits. Effective March 22, 2016, entitlement to a separate 10 percent rating for symptomatic residuals of a left knee meniscectomy, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a compensable rating for pulmonary embolus and residuals associated with right knee, status post total arthroplasty, is denied. REMANDED Entitlement to a rating in excess of 30 percent for irritable bowel syndrome (IBS) is remanded. FINDINGS OF FACT 1. Since January 1, 2016, the Veteran's right knee, status post total arthroplasty, has been manifested by symptoms of severe, painful motion and weakness. 2. For the entire appeal period, the Veteran has demonstrated a history of slight right knee lateral instability. 3. For the entire appeal period, the Veteran's left knee condition has been manifested by arthritis with pain on motion, with noncompensable limitation of flexion and extension. 4. For the entire appeal period, the Veteran has demonstrated a history of slight left knee lateral instability. 5. For the entire appeal period, the Veteran has exhibited left knee post-meniscectomy residuals of locking and occasional swelling. 6. For the entire appeal period, the competent and probative evidence of record demonstrates that the Veteran's status post pulmonary embolus and residuals associated with right knee, status post total arthroplasty, has not been manifested by residuals. CONCLUSIONS OF LAW 1. From January 1, 2016 to June 3, 2016, the criteria for a 60 percent rating for residuals of right knee arthroplasty have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020). 2. For the entire appeal period, the criteria for a rating in excess of 60 percent for residuals of right knee arthroplasty have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 3. The criteria for the award of a separate 10 percent rating for right knee slight instability for the entire appeal period have been met, effective January 1, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 4. The criteria for a rating in excess of 10 percent for left knee degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. 5. Effective March 22, 2016, the criteria for the award of a separate 10 percent rating for left knee slight instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. Effective March 22, 2016, the criteria for the award of a separate 10 percent rating for symptomatic residuals of a left knee meniscectomy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259. 7. The criteria for a compensable rating for pulmonary embolus and residuals associated with right knee, status post total arthroplasty, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.97, Diagnostic Code 6817. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1985 to September 1985. He testified before the undersigned at a videoconference in March 2019; a transcript of the hearing is associated with the claims file. This appeal was previously before the Board in September 2019. Increased Ratings 1. Entitlement to a rating in excess of 30 percent from January 1, 2016 to June 3, 2016 and in excess of 60 percent from June 3, 2016, for right knee, status post total arthroplasty. 2. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease associated with right knee degenerative joint disease. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that, effective February 7, 2021, VA revised the rating criteria for various Diagnostic Codes pertaining to the knee. 85 Fed. Reg. 76453 (November 30, 2020). When the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the veteran may be entitled to resolution of his claim under the criteria that are to his advantage. The former rating criteria may be applied throughout the period of the appeal if they are more favorable to him. The revised rating criteria may be applied only prospectively, however, from the effective date of the change forward unless the regulatory change specifically permits retroactive application. 38 U.S.C. § 5110(g); VAOPGCPREC 7-03; VAOPGCPREC 3-00; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board will address the revised rating criteria where applicable. The Veteran seeks higher ratings for his service-connected knee disabilities. Currently, the Veteran's right knee is rated as 30 percent disabling from January 1, 2016 to June 3, 2016 and as 60 percent disabling thereafter, pursuant to Diagnostic Code 5055. The Veteran's left knee condition is rated as 10 percent disabling pursuant to Diagnostic Code 5003-5260 throughout the entire appeal period. 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. 38 C.F.R. § 4.27. The former Diagnostic Code 5055 provides that a 30 percent rating is the minimum rating available after prosthetic replacement of a knee joint. A 60 percent rating is warranted where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion should be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a. The revised Diagnostic Code 5055, for knee, resurfacing or replacement (prosthesis) allows for a 100 percent rating for 4 months following implantation of prosthesis or resurfacing. A 30 percent rating is the minimum evaluation available after a total replacement only. A 60 percent rating is warranted where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion should be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. A Note adds that at the conclusion of the 100 percent evaluation period, evaluation resurfacing under diagnostic codes 5256 through 5262; there is no minimum evaluation for resurfacing. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees and a 30 percent rating is warranted where extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA's General Counsel has stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Under Diagnostic Code 5257, 10, 20, and 30 percent ratings are warranted for slight, moderate, or severe recurrent subluxation or lateral instability, respectively. Effective February 7, 2021, Diagnostic Code 5257 was revised. Under the revised rating criteria, a 30 percent disability rating is warranted for unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribed both an assistive device (e.g., cane(s), crutch(es), walker). Alternatively, a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective February 7, 2021). Note (1) to Diagnostic Code 5257 notes that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) to Diagnostic Code 5257 notes that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under Diagnostic Code 5258, a maximum 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Diagnostic Code 5259 holds that symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating, which is the maximum rating under that diagnostic code. Right Knee In November 2014, the Veteran filed a claim for a temporary total rating for his right knee after undergoing a total right knee arthroplasty in November 2014. His disability is rated as 100 percent disabling from November 6, 2014, 30 percent disabling from January 1, 2016, and 60 percent disabling from June 3, 2016, pursuant to Diagnostic Code 5055 (knee replacement). In connection with his November 2014 claim, the Veteran submitted evidence that he underwent a right knee arthroplasty in November 2014. The March 2015 rating decision assigned a 30 percent rating effective January 1, 2016, based on the minimum evaluation allowable following prosthetic replacement of the knee joint. In February 2016, the Veteran told his VA provider that he was experiencing bilateral knee pain and said that he could walk about six blocks before his knee would give out and buckle. He said it felt unstable. Later in February 2016, the Veteran was fitted for knee braces and told his provider that he had weakness and instability in his right knee. In a December 2016 statement, the Veteran indicated that he had pain, swelling, and stiffness in his knees and that he had right knee sprain. He said the pain his knees occurred daily. At his March 2019 Board hearing, the Veteran testified that his right knee locked up, that he was unable to walk for any distance and when he did, his leg swelled up from the knee down. He said he felt pain in his knee joint as well as weakness, locking, and instability. He said he could not straighten his right leg and that at least once a month, he felt like he was going to fall because of instability. In an August 2019 Brief, the Veteran's attorney contended that the right knee condition warranted a higher rating, insofar as the Veteran experienced throbbing, shooting pain, and instability of the right knee. The Veteran underwent another VA examination in December 2019. He said his right knee had progressively worsened and that he experienced daily locking, tenderness at the kneecap, and pain and strain after prolonged walking or standing. He reported flare-ups that occurred after standing or walking for about 5 minutes that manifested in pain. Range of motion testing showed right knee flexion to 90 degrees with extension to 0 degrees, with pain. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion. Though the examination did not take place during a flare-up, the examiner opined that the Veteran would likely have flexion to 80 degrees during a flare-up, given the Veteran's descriptions. There was a history of slight lateral instability but no noted history of recurrent effusion. The examiner noted normal joint stability. The examiner described the Veteran's residuals from his total joint knee replacement as severe. A healed, stable, 17 x 0.2-centimeter scar was noted on the Veteran's right anterior knee. It did not result in loss of skin or tissue. The Board notes that this scar is separately service connected. In light of the foregoing, the Board finds that a rating of 60 percent is warranted for the entire appellate period, i.e., since January 1, 2016, the day following the expiration of the temporary total rating that is in effect from November 6, 2014. In this regard, the AOJ has already assigned a 60 percent rating, based on chronic residuals consisting of severe painful motion or weakness in the affected extremity, as of June 3, 2016. The evidence does not indicate that there was a specific increase at that time; rather, based on the statements the Veteran gave to his VA provider in February 2016, the Veteran's right knee condition has been manifested by severe painful motion and/or weakness ever since his arthroplasty. Accordingly, the Board finds that the 60 percent rating should be effective as of January 1, 2016. In reaching this conclusion, the Board has also considered whether it would be more beneficial to the Veteran to rate the right knee residuals under diagnostic codes for limitation of flexion, extension, and instability. However, for the reasons explained, the Board finds that a 60 percent rating under Diagnostic Code 5055 is more beneficial than what he would receive if rated under another diagnostic code. As noted above, there is no evidence, lay or medical, that the Veteran has right knee ankylosis; therefore, a higher rating under Diagnostic Code 5256 is not warranted. Even if the Board were to consider and rate limitation of extension and flexion separately based on his lowest test results during the appeal period (limitation to 0 degrees of extension, and to 80 degrees of flexion, during a flare-up), such combined ratings under Diagnostic Codes 5260 and 5261 would combine to well less than the 60 percent currently assigned under Diagnostic Code 5055. The Board, however, does find that a separate rating is available under Diagnostic Code 5257, which governs ratings of recurrent subluxation or lateral instability of the knees, because that symptomatology is not considered by Diagnostic Code 5055. The former and revised criteria for Diagnostic Code 5257 are outlined above. Here, the Veteran has reported symptoms of "giving out" and instability throughout the appeal period. Indeed, the December 2019 VA examiner noted a history of slight lateral instability. Accordingly, as the instability has been described as "slight," as recently as December 2019, the Board finds that a separate, 10 percent rating, but no higher, pursuant to Diagnostic Code 5257 for the Veteran's right knee condition is warranted. The Board adds that assigning a rating for instability under Diagnostic Code 5257 separate from the 60 percent rating under Diagnostic Code 5055 based on the unique facts of this case does not violate the anti-pyramiding rule. See 38 C.F.R. § 4.14. This is because the symptomatology and manifestations are not duplicative or overlapping. The 60 percent rating under Diagnostic Code 5055 contemplates the Veteran's painful motion and weakness in the joint; the symptoms of subluxation and instability represent separate symptomatology that are properly rated separately under Diagnostic Code 5257. The revised rating criteria do not allow for a higher, 20 percent rating. In this regard, the Veteran's most recent VA examination in December 2019 specifically shows that he does not have a ligament tear or a patellofemoral condition, which would be required for an increased, 20 percent rating under the revised Diagnostic Code 5257. Accordingly, a separate rating of 10 percent under former Diagnostic Code 5257 is also warranted from January 1, 2016 to the present. The Board notes that the law does not permit the Board to assign separate ratings under both Diagnostic Codes 5055 and 5258 for disability of the same knee during the same period, as both Codes rate based on pain and effusion as forms of limitation of motion; therefore, assigning separate ratings under both Codes at the same time would violate the rule against pyramiding. 38 C.F.R. § 4.14. Finally, as the December 2019 VA examination indicates that there is no meniscal condition, tibia or fibula impairment, or genu recurvatum, ratings under Diagnostic Codes 5259, 5262, and 5263 are not warranted. Left Knee By way of history, a June 2014 rating decision granted service connection for left knee degenerative joint disease and assigned a 10 percent rating effective September 17, 2007. The Veteran filed an increased rating claim in March 2016, and in his May 2016 Notice of Disagreement, contended that he was seeking the maximum evaluation available under the law for his left knee condition. The Veteran's left knee degenerative joint disease has been rated as 10 percent disabling pursuant to Diagnostic Code 5003-5260 throughout the appeal period. In connection with his March 2016 claim, the Veteran underwent a VA examination in April 2016. He told the examiner he had aching pain that occurred when he walked one block or more and at night. He said he was limited to walking no more than six blocks before his knee gave out. He also noticed "buckling" of the knee if he walked too far or climbed stairs, and said he noticed some swelling after repeated use. He denied flare-ups of the left knee. Range of motion testing showed left knee flexion to 110 degrees with full extension. There was no evidence of pain with weight bearing. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without additional functional loss or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time but the examiner noted that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner indicated that there was no history of recurrent subluxation or lateral instability, no history of recurrent effusion, and no ankylosis. The examiner also noted that there was no history of a meniscus condition. The Veteran underwent imaging in June 2016 and subsequently underwent six physical therapy sessions at which the therapist recorded a patient history of pain and swelling for the past year that was worsening and affected the Veteran's sleep. The therapist observed edema, tenderness to palpation, an altered gait, knee clicking, and weakened strength. At his March 2019 Board hearing, the Veteran said that his left knee was getting worse. Specifically, he noted that he experienced pain, weakness, popping, and limited range of motion. He also said that it sometimes swelled above the kneecap. At a December 2019 VA knee examination, the Veteran reported daily left knee locking, tenderness at the kneecap, pain and strain after prolonged walking or standing. He said he wore a brace. He reported flare-ups that manifested in pain that occurred after walking for about 5 minutes. He said the flare-ups occurred daily. Range of motion testing showed left knee flexion to 90 degrees with full extension. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion. The examiner estimated that after repetitive use or during a flare-up, the Veteran would have left knee flexion to 80 degrees with full extension. The examiner recorded a slight history of lateral instability on the left side with no history of recurrent effusion, no ankylosis, no tibial or fibular impairment, and no genu recurvatum. The examiner noted that the Veteran had undergone a left knee meniscectomy in 2007 and experienced current residuals of pain, strain, and frequent knee locking. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's left knee condition. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, swelling, and feelings of the knee popping. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation would not result in limitation of motion more nearly approximately flexion limited to 30 degrees. In this regard, at the June 2014 VA examination, left knee flexion was shown to be to 110 degrees. More recently, at the December 2019 VA examination, the examiner estimated that the Veteran's flexion would be limited to 80 degrees, at worst, during a flare-up or after repetitive use. Given those medical findings, taken with the Veteran's lay statements, there is no basis on which to assign a higher rating under Diagnostic Code 5260. As the Veteran's left knee extension has never been shown to be limited to 10 degrees or greater, a separate rating under Diagnostic Code 5261 is not warranted. The Board has considered whether a separate rating is warranted pursuant to Diagnostic Code 5257 based on lateral instability or subluxation. In this regard, the medical evidence shows that in December 2019, the Veteran was noted to have a slight history of left knee lateral instability, a finding that comports with the Veteran's statements during the appeal period that his left knee was unstable and sometimes gave out. Accordingly, the Board finds that a separate, 10 percent rating, pursuant to Diagnostic Code 5257 is warranted during the appeal period, i.e., since March 22, 2016. For the same reasons as noted with the right kneein that the Veteran does not have a left knee diagnosed ligament tear or patellofemoral conditiona higher rating under the revised criteria is also not warranted. The Board also notes that the Veteran has complained of locking and swelling in his left knee. Specifically, he told the June 2014 examiner that his left knee swelled after use. At his March 2019 Board hearing, he noted that he sometimes had swelling above the left kneecap. Importantly, the Veteran underwent a meniscectomy prior to the appeal period under review. As noted above, under Diagnostic Code 5258, a maximum 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Diagnostic Code 5259 holds that symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating, which is the maximum rating under that diagnostic code. As discussed above, the Veteran's left knee pain symptomatology is already contemplated in the current 10 percent rating in effect, as the rating is specifically authorized under the provisions of 38 C.F.R. § 4.59 (painful motion) and the presence of degenerative arthritis. Given that the rating criteria under 5258 are conjunctivemeaning that frequent locking, pain and effusion must be present to warrant the assignment of the 20 percent ratingthe award of a separate rating under Diagnostic Code 5258 would effectively compensate the Veteran's pain symptoms twice, resulting in impermissible pyramiding. Nevertheless, as the Veteran did undergo a meniscectomy, and he does experience symptoms other than pain, to specifically include locking and occasional swelling after use, the Board finds that a separate 10 percent rating under Diagnostic Code 5259 is warranted throughout the period under review, since March 22, 2016. The Board adds that the rating criteria for Diagnostic Codes 5258 and 5259 were not revised. The evidence does not show that the Veteran experiences ankylosis; impairment of the tibia and fibula, or genu recurvatum in his left knee. Thus, separate or higher ratings under Diagnostic Codes 5256, 5262, and 5263 are not warranted. The Board finally notes that no examiners have identified any left knee scars. In sum, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for left knee degenerative joint disease. However, a separate 10 percent rating for slight lateral instability is granted effective March 22, 2016. A separate 10 percent rating for symptomatic residuals of a left knee meniscectomy is also granted effective March 22, 2016. The Board adds that it has considered whether the higher ratings may be made effective during the one-year look back period prior to the date of the increased rating claim in March 22, 2016, but it is not factually ascertainable that an increase in severity took place during that time period. 3. Entitlement to a compensable rating for pulmonary embolus and residuals associated with right knee, status post total arthroplasty. The April 2016 rating decision on appeal granted a noncompensable (zero) rating for pulmonary embolus associated with the Veteran's service-connected right knee condition. The Veteran asserts that he is entitled to a higher rating. The disability is rated pursuant to Diagnostic Code 6817. Under Diagnostic Code 6817, a noncompensable rating is warranted for asymptomatic pulmonary vascular disease, following resolution of pulmonary thromboembolism. A 30 percent rating is warranted for pulmonary vascular disease that is symptomatic, following resolution of acute pulmonary embolism. A 60 percent is warranted for chronic pulmonary thromboembolism requiring anticoagulant therapy, or; following inferior vena cava surgery without evidence of pulmonary hypertension or right ventricular dysfunction. A 100 percent rating is warranted for primary pulmonary hypertension, or; chronic pulmonary thromboembolism with evidence of pulmonary hypertension, right ventricular hypertrophy, or cor pulmonale, or; pulmonary hypertension secondary to other obstructive disease of pulmonary arteries or veins with evidence of right ventricular hypertrophy or cor pulmonale. The rating criteria also instruct the adjudicator to "evaluate other residuals following pulmonary embolism under the most appropriate diagnostic code, such as chronic bronchitis (Diagnostic Code 6600) or chronic pleural effusion or fibrosis (Diagnostic Code 6845), but do not combine that evaluation with any of the above evaluations." Id. at Note [1]. In connection with his March 2016 claim, the Veteran underwent a VA examination in April 2016. It was noted that after his November 2014 total knee replacement he developed evidence of pulmonary emboli, and a subsequent CT scan of the thorax revealed some small nonocclusive pulmonary emboli in the distal segmental branches of some arteries of the right and left upper lobes of the lung. He was treated with an anticoagulant until June of 2015 and there had been no complications or recurrence since then. The condition did not require the use of medication, oral bronchodilators, antibiotics, or oxygen therapy. The examiner noted that the condition was asymptomatic, following resolution of pulmonary thromboembolism. No other findings or complications were noted. In his May 2016 Notice of Disagreement, the Veteran asserted that he was seeking the maximum evaluation available under the law, but did not explain the symptoms he had that would warrant a higher evaluation. In a December 2016 statement, the Veteran recounted the symptoms he had when the blood clot first appeared in 2014 but did not address his current symptoms. At his March 2019 Board hearing, the Veteran testified that he experienced severe shortness of breath, chest pain, swelling in his legs, and excessive sweating. In an August 2019 brief, the Veteran's attorney indicated that the Veteran experienced symptoms including shortness of breath, reduced endurance, chest pain, leg swelling, rapid heartbeat, and excessive sweating. The attorney pointed to a VA treatment note from December 2018 showing that the Veteran sought emergency treatment for a swollen left calf that he thought could be complications of his embolism. The attorney noted studies which stated that symptoms could persist long after the pulmonary embolus had resolved. The description of his symptoms prompted an additional VA examination, which took place in December 2019. The Veteran told the VA examiner that he experienced shortness of breath and became easily tired. In comments, the examiner indicated that although the Veteran reported continuing fatigue, there was no objective evidence of a current pulmonary embolism or any treatment for blockage or obstruction in the pulmonary arteries of the Veteran's lungs. VA treatment records show that the Veteran denied experiencing shortness of breath and/or chest pain in December 2017, March 2018, February 2019, August 2019, and September 2019. Based on the foregoing, the Board concludes that a compensable rating is not warranted for the Veteran's pulmonary embolism residuals. In this regard, the April 2016 VA examiner indicated that the condition was asymptomatic, and the December 2019 VA examiner indicated that despite the Veteran's reports of fatigue, there was no evidence of a current pulmonary embolism or any treatment for blockage or obstruction in the pulmonary arteries of the Veteran's lungs. In other words, the examiner did not find any symptomatic residuals of his prior embolism. The Board has considered the Veteran's lay statements at his Board hearing and the statements made in the August 2019 Attorney's Brief that the Veteran experiences severe shortness of breath, chest pain, leg swelling, and excessive sweating, as well as the statements made to the December 2019 VA examiner that he experienced shortness of breath and fatigue. While the Veteran is competent to report the symptoms he experiences, he is not competent to relate those symptoms to a specific disability, as such requires specialized medical knowledge. In this case, two medical providers have essentially indicated that there are no residuals stemming from the pulmonary embolism that occurred in 2014 following the Veteran's right knee arthroplasty. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for a higher rating for residuals of pulmonary embolism. The benefit-of-the-doubt rule does not apply, and entitlement to a compensable disability rating for pulmonary embolism is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND Entitlement to a rating in excess of 30 percent for irritable bowel syndrome (IBS) is remanded. The Veteran filed a service-connection claim for irritable bowel syndrome in March 2016 and in an April 2016 rating decision, the AOJ assigned a noncompensable (zero percent) rating pursuant to Diagnostic Code 7319. Following an examination in December 2019, the Veteran's rating was increased to 30 percent disabling by way of an April 2020 rating decision. The rating decision noted that the 30 percent rating was the highest schedular rating allowable under Diagnostic Code 7319 and that therefore the award of a higher rating represented a full grant of the benefit sought on appeal. Given that finding, the issue was not addressed in a separately issued supplemental statement of the case in April 2020. However, for the reasons that follow, the Board finds that there was not substantial compliance with the September 2019 Remand, and that the issue must be remanded again. In this regard, in an August 2019 Brief, the Veteran's attorney indicated that the Veteran had been diagnosed with C. difficile, diverticulitis, and internal and external hemorrhoids - diagnoses that are reflected in the Veteran's treatment records - and that his disability should have been rated as 60 percent disabling under Diagnostic Code 7323, for ulcerative colitis. Given those contentions, the Board requested that the Veteran undergo gastrointestinal examinations, including stomach conditions, intestinal conditions, and intestinal surgery examinations; however, the Veteran was only afforded an intestinal conditions examination where the examiner did not address any diagnoses other than IBS. Given the attorney's contentions, the notations in the Veteran's treatment records that he has other gastrointestinal conditions including C. difficile, hemorrhoids, and diverticulosis, the Board finds that the Veteran should undergo additional examinations. The matter is REMANDED for the following action: 1. Arrange for the Veteran to undergo VA intestinal surgery, intestinal conditions, and stomach conditions examinations, to assess the current nature and severity of the Veteran's IBS. The examiner(s) should take a history from the Veteran as to the progression of his service-connected IBS and provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. Any necessary testing should be performed. The examiner(s) must address the other health concerns/diagnoses noted throughout the Veteran's VA treatment records, including hemorrhoids, diverticulosis, and C. difficile, and indicate whether such are manifestations of, or otherwise associated with service-connected IBS. If so, please indicate their severity. (Continued on Next Page) 2. Then, readjudicate the issue on appeal with consideration of all relevant diagnostic criteria. If the benefit sought remains denied, in whole or in part, issue the Veteran and his attorney a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.