Citation Nr: A21013736 Decision Date: 08/16/21 Archive Date: 08/16/21 DOCKET NO. 190828-57596 DATE: August 16, 2021 ORDER A compensable rating for anorexia nervosa (anorexia) is denied. REMANDED Service connection for irritable bowel syndrome (IBS) is remanded. Service connection for an eye disability is remanded. Service connection for a disability resulting in sexual dysfunction, to include female sexual arousal disorder (FSAD) is remanded. FINDING OF FACT The Veteran's anorexia has not resulted in incapacitating episodes. CONCLUSION OF LAW The criteria for a compensable rating for anorexia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9520. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1993 to October 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2019 rating decision of the Agency of Original Jurisdiction (AOJ). In August 2019, the Veteran submitted a Decision Review Request: Board Appeal (Notice of Disagreement) under the Appeals Modernization Act (AMA), at which time she elected to participate in a hearing before a Veterans Law Judge (VLJ). The Veteran participated in a hearing before the undersigned VLJ in April 2021, and a transcript of this hearing has been associated with the record. With the Veteran's election of the Board's hearing docket, the Board's decision is based on a review of the evidence of record at the time of the July 2019 rating decision, evidence submitted during the Veteran's April 2021 hearing, and evidence submitted within 90 days after such hearing. See 38 C.F.R. § 20.302. The Board cannot consider evidence submitted outside of these evidentiary windows. See 38 C.F.R. § 20.300. To the extent that the Veteran wishes for such evidence to be considered, she may file a Supplemental Claim. See 38 C.F.R. § 3.2501. If the Veteran submits new and relevant evidence, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Anorexia is rated based on the Rating Formula for Eating Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9520. Under this formula, a noncompensable rating applies to binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder but without incapacitating episodes, is to be rated as noncompensable. A 10 percent rating applies to binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder and incapacitating episodes of up to two weeks total duration per year. A 30 percent rating applies to self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of more than two but less than six weeks total duration per year. A 60 percent rating applies to self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of six or more weeks total duration per year. A 100 percent rating applies to self-induced weight loss to less than 80 percent of expected minimum weight, with incapacitating episodes of at least six weeks total duration per year, and requiring hospitalization more than twice a year for parenteral nutrition or tube feeding. An "incapacitating episode" is a period during which bed rest and treatment by a physician are required. Turning to the facts in this case, the Veteran filed a claim for service connection for anorexia in April 2019. The Veteran underwent a VA examination in May 2019, at which time the examiner diagnosed the Veteran with anorexia, but found that such disability did not result in incapacitating episodes or any other symptoms. The Veteran's medical treatment records do not show the Veteran's anorexia requiring any periods of bed rest and treatment by a physician. In April 2019, a clinician noted that the Veteran's weight was stable. The Veteran's weight remained the same between February 2019 and May 2019. She maintained a body mass index of 22. During her April 2021 hearing before the undersigned, the Veteran stated that she had been prescribed bed rest in treatment of her anorexia, and that she spent most of her time resting as a result of the weakness that she experienced as a result of her anorexia. In June 2021, a private psychologist noted that the Veteran's anorexia resulted in her abuse of laxatives. Turning to an analysis of these facts, a compensable rating for anorexia requires the presence of incapacitating episodes, which are periods of bed rest and treatment by a physician. The Board has considered the Veteran's lay statements that she often rests as the result of the weakness associated with her anorexia. These lay statements do not themselves establish the presence of incapacitating episodes, because the weight of the medical evidence does not show that the Veteran's anorexia has been treated with physician-prescribed bed rest at any time. Without medical evidence of such incapacitating episodes, a compensable rating for anorexia is denied. REASONS FOR REMAND Service Connection for IBS The Board must remand the Veteran's claim for service connection for IBS to correct a pre-decisional error in VA's duty to assist the Veteran. 38 U.S.C. § 5103A(f); 38 C.F.R. § 20.802(a). The Veteran claims that she had IBS as the secondary result of her service-connected disabilities, which include posttraumatic stress disorder (PTSD) and anorexia, in pertinent part. More specifically, the Veteran has argued, for example during her April 2021 hearing before the undersigned, that her IBS relates either to the psychological stress associated with her PTSD or to the "abuse of . . . laxatives" associated with her anorexia. The Veteran's medical treatment records suggest that the Veteran has a chronic IBS disability. The Veteran underwent an examination in May 2019, at which time the examiner both diagnosed the Veteran with IBS and stated that a chronic current diagnosis could not be confirmed. The examiner additionally stated, without further explanation, that the examiner did "not feel as though the IBS is associated with her PTSD because of her laxative use". The Board finds that the May 2019 opinion is inadequate. The examination report does not clearly indicate whether the Veteran has a current diagnosis of a chronic IBS disability. While the examiner opined that the Veteran's IBS was not associated with her PTSD, the examiner did not explain this conclusion, did not opine as to whether IBS was caused by anorexia, and did not opine as to whether IBS was aggravated by PTSD or anorexia. To correct this error, the Board must remand the Veteran's claim in order to afford her with an additional examination clarifying the nature and etiology of her IBS. Service Connection for an Eye Disability The Board must remand the Veteran's claim for service connection for an eye disability to correct a pre-decisional error in VA's duty to assist the Veteran. 38 U.S.C. § 5103A(f); 38 C.F.R. § 20.802(a). The Veteran claims that she had an eye disability as the secondary result of her service-connected disabilities, which include PTSD, migraine headaches, anorexia, and anemia. In May 2019, an examiner indicated that the Veteran experienced changes in her vision as a symptom of her migraine headache disability. In July 2019, an examiner diagnosed the Veteran with palinopsia, which the examiner indicated was not a congenital or developmental error of refraction. The examiner opined that the Veteran's eye disability was "likely due to migraines or systemic medications". The Board finds that the July 2019 opinion is inadequate. The examination report does not clearly identify whether the Veteran's palinopsia is a disability that is separate and distinct from her service-connected migraine headache disability, or whether palinopsia is a symptom associated with her migraine headache disability. To correct this error, the Board must remand the Veteran's claim in order to afford her with an additional examination clarifying the nature and etiology of her eye disability. Service Connection for a Disability Resulting in Sexual Dysfunction The Board must remand the Veteran's claim for service connection for a disability resulting in sexual dysfunction, to include FSAD, to correct a pre-decisional error in VA's duty to assist the Veteran. 38 U.S.C. § 5103A(f); 38 C.F.R. § 20.802(a). The Veteran claims that she experiences sexual dysfunction as the secondary result of her service-connected disabilities, which, the Board notes, includes PTSD that has been granted as the result of a military sexual trauma. The Veteran underwent a VA examination in May 2019, at which time the Veteran described experiencing difficulties engaging in sexual intercourse with her spouse as the result of her PTSD symptoms. The examiner stated that the Veteran did not have FSAD and otherwise opined, without further explanation, that the Veteran did not have a currently diagnosed disability. The Board finds that the May 2019 opinion is inadequate. The examination report does not explain why the sexual dysfunction described by the Veteran is not itself a disability. Furthermore, the examiner does not discuss whether sexual dysfunction is a disability that is separate and distinct from her service-connected PTSD, or whether such dysfunction is a symptom associated with her service-connected PTSD. To correct this error, the Board must remand the Veteran's claim in order to afford her with an additional examination clarifying the nature and etiology of her disability resulting in sexual dysfunction. This matter is REMANDED for the following action: Schedule the Veteran for VA examinations addressing the nature and etiology of her IBS, eye disability, and disability resulting in sexual dysfunction. After reviewing the Veteran's electronic claims file and considering the Veteran's contentions, the examiner should: With respect to IBS: (a.) Explain whether the Veteran has a current diagnosis of IBS. When rendering this decision, the examiner should note that the Veteran's VA treatment records consistently include IBS in the Veteran's current problem list. (b.) If the examiner diagnoses the Veteran with IBS, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that IBS is proximately due to the Veteran's service-connected disabilities, including PTSD and anorexia, to include the laxative use that has been associated with such disabilities. (c.) If the examiner diagnoses the Veteran with IBS, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that IBS underwent an incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected disabilities, including PTSD and anorexia, to include the laxative use that has been associated with such disabilities. The term "incremental increase in disability" means an additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. With respect to an eye disability: (a.) Diagnose all of the Veteran's eye disabilities, to include palinopsia. (b.) For each diagnosed eye disability, state whether such disability is separate and distinct from the Veteran's service-connected migraine headache disability, or whether such disability is a symptom attributable to the Veteran's service-connected migraine headache disability. (c.) For any diagnosed eye disability that is separate and distinct from the Veteran's service-connected migraine headache disability, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that such eye disability is proximately due to the Veteran's service-connected disabilities, including PTSD, migraine headaches, anorexia, and anemia. (d.) For any diagnosed eye disability that is separate and distinct from the Veteran's service-connected migraine headache disability, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that such eye disability underwent an incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected disabilities, including PTSD, migraine headaches, anorexia, and anemia. The term "incremental increase in disability" means an additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. With respect to a disability resulting in sexual dysfunction, to include FSAD: (a.) State whether the Veteran's credible complaints of experiencing sexual dysfunction is a disability that is separate and distinct from service-connected PTSD, or whether such dysfunction is a symptom attributable to the Veteran's service-connected PTSD. (b.) If the Veteran's sexual dysfunction is a disability that is separate and distinct from service-connected PTSD, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that such sexual dysfunction is proximately due to the Veteran's service-connected disabilities, including PTSD. (c.) If the Veteran's sexual dysfunction is a disability that is separate and distinct from service-connected PTSD, address whether it is it at least as likely as not (that is, a probability of 50 percent or greater) that such sexual dysfunction underwent an incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected disabilities, including PTSD. The term "incremental increase in disability" means an additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.A. Flynn, 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.