Citation Nr: 22048552 Decision Date: 08/25/22 Archive Date: 08/25/22 DOCKET NO. 16-00 200 DATE: August 25, 2022 REMANDED Entitlement to an initial increased rating, in excess of 10 percent disabling, for periodic limb movement syndrome (PLMD) of the left lower extremity, with features of restless leg syndrome (LLE PLMD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1983 to May 2015. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office in Fort Harrison, Montana. In a November 2015 Rating Decision from a decision review officer, the non-compensable rating for the service-connected LLE PLMD was increased to 10 percent, effective June 1, 2015. However, this is not representative of a full grant of benefits sought, and thus, this issue remains on appeal. In June 2019 and June 2020, the Board remanded this matter to the Regional Office for further evidentiary development. Subsequently, in a November 2020 rating decision, the Regional Office granted service connection for PLMD, with features of restless leg syndrome in the right lower extremity (RLE PLMD). However, as the November 2020 rating decision indicates, the Regional Office has rated RLE PLMD separately from LLE PLMD. Therefore, the Board clarifies that the issue of an increased rating for RLE PLMD, as a separate rating, is not currently before the Board on appeal. Nonetheless, as this issue is not appropriately before the Board, the Veteran may opt to file a new increased rating claim for RLE PLMD. Most recently, in January 2022, the Board remanded the issues for further development. 1. Entitlement to an initial increased rating, in excess of 10 percent disabling, for periodic limb movement syndrome (PLMD) of the left lower extremity, with features of restless leg syndrome (LLE PLMD). The Board regrets the additional delay, however, remand is required to obtain a new medical opinion which properly evaluates the severity of the Veteran's LLE PLMD, and ensures compliance with the Board's previous remand directives regarding the issue on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran's LLE PLMD is currently rated as 10 percent disabling under Diagnostic Code 8199-8103. As there is no specific diagnostic code for periodic limb movements, it must be rated against the diagnostic code that most closely approximates the Veteran's disability. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. See 38 C.F.R. § 4.27. An unlisted disease, injury, or residual condition is rated by analogy with the first two digits selected from that part of the rating schedule that most closely identifies the part or system of the body involved; the last two digits will be "99" for all unlisted conditions. In this case 8199 refers to neurological conditions and convulsive disorders, while 8103 refers to the convulsive tic diagnostic code. Thus, the Veteran's PLMD is currently rated by analogy to a convulsive tic. Pursuant to Diagnostic Code 8103, a mild disability warrants a 0 percent rating, a moderate disability warrants a 10 percent rating, and a severe disability warrants a 30 percent rating. In its January 2022 remand, the Board directed the RO to obtain an opinion on the etiology, diagnosis and severity of his limb movement disorder. Specifically, the Board directed the RO to: schedule the Veteran for a new VA examination with an appropriately qualified physician (VA examiner) to determine the current severity of his LLE PLMD. Further physical examination is left to the discretion of the examiner. Additionally, the Veteran should also be scheduled for a sleep study, for purposes of assessing the severity of leg movements and leg jerking during his sleep, and/or any related symptoms of LLE PLMD. In assessing the current severity of the Veteran's LLE PLMD, the VA examiner must undertake the following: a. Please provide a full description of the Veteran's disability, including any manifest symptoms, such as, for example, fatigue, leg jerking, and report all other signs and symptoms that are necessary for evaluating this disability under the rating criteria for DC 8103 (i.e., convulsive tic). b. To the extent possible, please identify any symptoms and functional impairments due to the LLE PLMD alone, and discuss the effect on any occupational functioning and activities of daily living, if any. In a June 2022 sleep study, the examiner noted that the Veteran had leg movements during sleep. The examiner indicated that the Veteran had over 40 leg movements, to include arousals and awakenings, during the study. The examiner noted that above 4.8 arousals per hour may be "significant." In a July 2022 addendum opinion, a VA examiner clarified the Veteran's diagnosis and affirmed that the condition was related to his military service. While the examiner notes frequent leg movements, which were confirmed during the June 2022 sleep study, the examiner did not provide a complete, adequate assessment of the symptomatology and severity of the Veteran's PLMD. For example, given the Veteran's history of a significant amount of leg movements, to include leg jerking during his sleep, which the VA examiner acknowledged, this VA examination report does not address the current severity (mild, moderate, severe) of his LLE PLMD. Therefore, the Board finds that there has not been substantial compliance with the January 2022 Board remand, in that the July 2022 VA examination is inadequate to adjudicate the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Thus, the Board finds that remand is required for a new VA examination, for purposes of identifying all symptoms attributable to the service-connected PLMD, as well as the severity of his PLMD. The matter is REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records from the Veteran's VA and private treatment providers and associate them with the claims file. The RO should document all attempts to obtain records. The RO should advise the Veteran on how to submit any additional records that may be in his possession. 2. Obtain an addendum opinion from an appropriate clinician to determine the current severity of his service-connected PLMD 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. In doing so, the examiner should provide an opinion on whether the findings of the June 2022 sleep study indicate a mild, moderate, or severe level of PLMD/RLS symptomatology. A clear rationale must be provided for all opinions rendered. If the examiner determines that it is not possible to provide an opinion without resorting to speculation, then the examiner must provide an explanation of why that is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge, a deficiency in the record, or a deficiency in the examiner's knowledge. Rahil Gandhi Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael J. O'Connor, 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.