Citation Nr: 22013262 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 16-41 894A DATE: March 9, 2022 REMANDED Entitlement to service connection for temporomandibular joint disorder (TMJ) is remanded. Entitlement to an initial compensable rating for hemorrhoids is remanded. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease, residuals of right ankle sprain is remanded. Entitlement to an initial rating in excess of 10 percent for right thumb scar is remanded. Entitlement to an initial rating in excess of 10 percent for residuals of right cerebral hemisphere infarction, with residual dizziness (vertigo) and tremors, predominant on left hand associated with hypertension, is remanded. Entitlement to a rating in excess of 30 percent for GERD/hiatal hernia with erosive gastritis is remanded. REASONS FOR REMAND The Veteran served on active from June 1986 to August 2006. This appeal comes before the Board of Veterans' Appeals (Board) from a July 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in October 2021, and a transcript of that hearing is of record. The Board finds remand necessary for the reasons addressed below. 1. Entitlement to service connection for temporomandibular joint disorder (TMJ) is remanded. During the Board hearing, the Veteran's spouse stated that the Veteran was diagnosed with TMJ in service. The Veteran reported current symptoms of his jaw clicking/popping and jaw pain but did not indicate having been diagnosed with TMJ post-separation. He denied any in-service jaw injury in service. Initially, the Board finds a brief explanation of the procedural history relevant here. Here, the RO issued a Statement of the Case (SOC) in June 2016. The Veteran timely filed a VA form 9 in August 2016. Subsequently, the Veteran submitted additional records after receiving a call from a DRO officer (which, unknown to the Veteran, was treated as a DRO hearing). Nonetheless, his case was closed out, without those additionally submitted records having been renewed, as the RO erroneously determined his VA form 9 was untimely. See October 2017 correspondence. It seems that the Veteran's August 2016 VA form 9 was only recently reactivated after having resolved the matter of the timeliness of this VA form 9 in favor of the Veteran. See April 2020 Deferred Rating. However, the RO has yet to review the relevant records associated with the claims file in between the time of the June 2016 SOC issuance and now. A remand is necessary for the AOJ to consider the new evidence and readjudicate this claim on appeal. 2. Entitlement to an initial compensable rating for hemorrhoids is remanded. 3. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease, residuals of right ankle sprain is remanded. 4. Entitlement to an initial rating in excess of 10 percent for right thumb scar is remanded. 5. Entitlement to an initial rating in excess of 10 percent for residuals of right cerebral hemisphere infarction, with residual dizziness (vertigo) and tremors, predominant on left hand associated with hypertension is remanded. 6. Entitlement to a rating in excess of 30 percent for GERD/hiatal hernia with erosive gastritis is remanded. During the hearing, the Veteran testified that his hemorrhoids, GERD/hiatal hernia disorder, right ankle disability, right thumb scar, and residuals of right cerebral hemisphere infarction disabilities have worsened. He was last afforded VA examinations for hemorrhoid, GI condition, right ankle disability, and right thumb scar condition in February 2014, and for his residuals of right cerebral hemisphere infarction disabilities in August 2018. Thus, remand is necessary to afford the Veteran a contemporaneous VA examination to determine the current severity of his symptoms. See Snuffer v. Gober, 10 Vet. App. 400 (1997). Specifically, with regards to hemorrhoids, the Veteran contends that he experiences internal hemorrhoids about once a month, for which he receives treatment from the VA. As for his GERD/hiatal hernia, he claims having to wake up during night and take more medications to avoid choking himself. He describes his symptom as sharp stomach pain, burning sensation in the throat, and tingling in the left arm. As for the right ankle disability, he reports his "walking has become very slow and limited" due to his right ankle pain. He states he has pain and occasional swelling, as well as stiffening/increased pain with increased activity/driving. Regarding the right thumb scar disability, he claims it would not heal (continues to be an open wound that bleeds) and remains unstable. With regards to the right cerebral hemisphere infarction residual condition, he reports having dizziness, which prevents him from walking at a normal pace and limits how far he can walk/sit, and tremors on the left hand, for which he also contends separate ratings should be warranted. He testified having seen private physicians once or twice for his headaches, during which time tremors were also noticed and a diagnosis of Parkinson's was provided. He testified that they speculated such symptoms to be related to his service-connected right cerebral hemisphere infarction residual. He also raised the adequacy of the January 2017 VA examination, noting that it was not conducted by a neurology specialist, but by a muscle therapist. Thus, on remand, in furnishing a VA examination for assessing the current severity, the examiner should also opine whether the additional neurological symptoms that the Veteran reports, to include vertigo/headaches and tremors, are manifestations of his service-connected right cerebral hemisphere infarction residual condition. Additionally, the Veteran testified that he receives treatment from VA for all of these conditions. The evidence of record only shows VA treatment records through October 2018. Thus, the Board finds it necessary to remand for also obtaining VA treatment records from November 2018. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records, to include any VA treatment records from November 2018 to the present. 2. After outstanding records are obtained to the extent possible, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hemorrhoids, GERD/hiatal hernia disorder, right ankle disability, right thumb scar. The entire claims file and this remand should be made available to the examiner. The examiner is directed to consider the Veteran's lay statements of his symptom having worsened. 3. Schedule an examination by an appropriate neurology specialist to determine the current severity of his service-connected residuals of right cerebral hemisphere infarction. The examiner should also determine whether any neurological manifestations, including dizziness (vertigo) and left hand tremors, the Veteran has experienced during the appeal period are residuals from his service-connected residuals of right cerebral hemisphere infarction. In doing so, the examiner should consider the Veteran's Board hearing testimony that his private physicians have once relayed that his additional neurological symptoms might be associated with his service-connected residuals of right cerebral hemisphere infarction. 4. After the above development, and any other development deemed necessary, review the record, to include all the evidence added since the June 2016 SOC, and readjudicate the claims, to include the service connection claim for TMJ. RO should also consider whether separate ratings are warranted for any neurological manifestations, such as tremors, headaches/vertigo. If the benefits sought on appeal remain denied, the Veteran and his attorney should be furnished a supplemental statement of the case and given the opportunity to respond thereto. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.