Citation Nr: 1014159 Decision Date: 04/14/10 Archive Date: 04/29/10 DOCKET NO. 08-27 348 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 20 percent for degenerative disc disease with spondyloarthritis, cervical spine at C4-5 and C5-6. 3. Entitlement to a rating in excess of 30 percent for residual right upper weakness and numbness. 4. Entitlement to service connection for a low back disorder, claimed as degenerative disc disease and degenerative spondyloarthritis of the lumbar spine. 5. Entitlement to service connection for a skin disorder, claimed as due to exposure to herbicides. ATTORNEY FOR THE BOARD A. M. Clark, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1969 to September 1971. These matters come before the Board of Veterans' Appeals (BVA or Board) from rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in St. Petersburg, Florida. During the pendency of the appeal, the RO granted a separate 30 percent rating, under Diagnostic Codes (DCs) 8599-8515, for neurological symptoms associated with the Veteran's service-connected cervical spine. The General Rating criteria, for diseases and injuries of the spine, treat neurological symptoms as components of a spine disability. As such, the Board will additionally consider, on appeal, whether a rating in excess of 30 percent is warranted for the Veteran's service-connected residual right upper weakness and numbness. The issues of entitlement to a rating in excess of 20 percent for degenerative disc disease with spondyloarthritis, cervical spine at C4-5 and C5-6 and entitlement to service connection for actinic keratosis, claimed as skin cancer, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. With respect to his claim for entitlement to a rating in excess of 30 percent for residual right upper weakness and numbness, the Board finds that this issue is inextricably intertwined with his increased rating claim for a cervical spine disorder. Therefore, the issue will be held in abeyance pending completion of the development discussed in the REMAND below. See Hoyer v. Derwinski, 1 Vet. App. 208, 209-10 (1991). FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's PTSD has been productive of serious but not total occupational and social impairment. 2. A chronic low back disorder was not manifest during service; lumbar spine pathology was not identified until January 1994; arthritis was not manifest to a degree of 10 percent or more within 1 year from the date of separation from service. 3. The current low back disorder is unrelated to service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code (DC) 9411 (2009). 2. A low back disorder, claimed as degenerative disc disease and degenerative spondyloarthritis of the lumbar spine was not incurred in or aggravated by service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 5103(a), 5103A (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating- PTSD Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2009). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2009). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2009). At the outset, the Board notes that the Veteran is appealing the initial disability rating assigned for his PTSD. As such, the claim requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD is currently evaluated as 70 percent disabling under DC 9411, in accordance with the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The Veteran maintains that his 70 percent rating should be increased to 100 percent disabling. Under the general rating formula, a 70 percent evaluation is warranted for PTSD if the Veteran exhibits: occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine actives; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A maximum 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. With respect to the schedular criteria used to rate PTSD, the evidence of record does not demonstrate any of the specific symptoms listed in the examples for the 100 percent rating under DC 9411. He has experienced no gross impairment of his thought process or communication; in fact his speech has been consistently normal (August 2006, private treatment note; November 2006, VA examination; August 2008, private treatment note; January 2009, VA examination). His thought processes were described as goal directed at his November 2006 VA examination, and as unremarkable at his January 2009 VA examination. The Veteran did indicate, at his November 2006 VA examination, that he had difficulty getting all of his thoughts put into words, due to being chocked up. The Veteran denied symptoms of deluded thoughts and auditory or visual hallucinations at an August 2006 private treatment visit, August 2008 private treatment visit, and January 2009 VA examination. With respect to the Veteran's memory, both his long term and short term memories were described as intact at August 2006 and August 2008 private treatment visits. The January 2009 VA examiner described the Veteran's remote and recent memory as being normal, while his immediate memory was described as being mildly impaired. The Veteran indicated that he frequently forgot to complete tasks. These findings do not rise to the level of disorientation to time and place or memory loss for close relative, his own name or occupation. The Veteran has additionally been consistently oriented to time and place. Private treatment notes from August 2006 and August 2008, and his November 2006 and January 2009 VA examinations noted that he was oriented to time and place. With respect to activities of daily living, the Board notes that a June 2006 private treatment note indicated that the Veteran had difficulty completing daily tasks. However, a November 2006 VA examination noted that he was able to perform his activities of daily living well. Further, his January 2009 VA examination noted that he did not have problems with activities of daily living and was able to maintain minimum personal hygiene. A 100 percent rating is also warranted under DC 9411, if a Veteran manifests persistent danger to himself or others. The Veteran denied suicidal and homicidal ideation at an August 2006 private treatment visit, November 2006 VA examination, and January 2009 VA examination. The Board has considered reports of chronic anger and rage problems. He reported at an August 2006 private treatment visit that he was frequently irritable and easily angered. Anger and irritability were also noted in a June 2006 letter written by his private treating physician. An August 2008 private treatment note indicated that the Veteran periodically engaged in physical altercations when feeling threatened or disrespected. He also reported a history of verbal and physical altercations at his January 2009 VA examination. Although the Veteran appears to have occasional difficulty with bursts of anger and rage, the evidence does not indicate he is in persistent danger of hurting others. The Veteran's other reported symptoms, including nightmares, intrusive thoughts, hypervigilance, avoidance, exaggerated startle response, difficulty with relationships, anxiousness, and irritability, are contemplated by the currently assigned disability evaluation of 70 percent. With respect to occupational impairment, the record does not establish that the Veteran is unable to work solely due to his PTSD. In fact, a July 2009 rating decision granted the Veteran a total disability rating based on individual unemployability (TDIU) based on his service-connected disabilities including PTSD, cervical spine, and residuals of right upper weakness and numbness. The Board recognizes that the January 2009 VA examiner noted that the Veteran had total occupational and social impairment due to PTSD signs and symptoms. However, a July 2008 letter, from the Veteran's private treating physician, indicated that the Veteran was incapable of securing and maintaining employment due to both his psychological issues and physical disabilities. In concluding that a disability rating in excess of 70 percent is not warranted here, the Board has also considered the Veteran's Global Assessment of Functioning (GAF) score assigned at his VA examinations. GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM IV)). Here, the November 2006 VA examination revealed a GAF score of 52, while the January 2009 VA examination revealed a GAF score of 50. Therefore, the GAF scores referable to the Veteran's PTSD range essentially from 50 to 52. In this regard, scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A GAF score of 41-50 indicates more serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Based on the above GAF scores, an evaluation in excess of 70 percent is not warranted for any portion of the rating period on appeal. The Board finds that the GAF scores are consistent with the rating already in effect. In reaching this conclusion, the benefit of the doubt doctrine has been applied where appropriate. The overall evidence therefore shows that the Veteran does not manifest total occupational impairment due to his PTSD. His GAF scores have been indicative of serious symptoms, but do not establish total impairment. The preponderance of the evidence is thus against a finding that the severity of his symptoms are contemplated by a 100 percent rating as his PTSD does not meet or approximate total occupational or social impairment. 38 C.F.R. §§ 4.7, 4.21. As the preponderance of the evidence is against the claim, reasonable doubt does not arise, and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002). With respect to the Veteran's claim, the Board has also considered the statements of the Veteran and his wife that his disability is worse. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran and his wife are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses. Layno, 6 Vet. App. at 470. They are not, however, competent to identify a specific level of disability of this disorder-according to the appropriate diagnostic codes. Such competent evidence-concerning the nature and extent of the Veteran's PTSD disability-has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable and the appeal is denied. Next, the Board will consider whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Under the provisions of 38 C.F.R. § 3.321(b)(1) (2009), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. Therefore, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed.Cir. Jul 17, 2009). The Board finds that the schedular criteria are adequate to describe the severity and symptoms of the Veteran's disability. His PTSD has been manifested by no more than serious symptoms, such as sleep problems, intrusive thoughts, hypervigilance, anger and rage, and severe occupational and social impairment. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. Id. II. Service Connection- Lumbar Spine Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2009). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2009). Further, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d) (2009). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In considering the claim for service connection for a lumbar spine disorder, the Board begins by considering whether his disability existed prior to service. In this regard, a veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. § 1111 (West 2002). In assessing whether the Veteran was in sound condition upon entry to service, the service treatment records have been reviewed. The Board has considered an October 1968 letter, from his private treating physician, indicating that the Veteran had been treated for a moderate low-back strain, prior to service. Additionally, the Veteran reported a history of recurrent back pain in a report of medical history completed at entrance in June 1969. However, the Veteran's June 1969 enlistment examination revealed a normal clinical evaluation of his spine. As there was no defect of the Veteran's spine noted on entry, and there is no clear and unmistakable evidence of record showing that his low back disorder preexisted service, the presumption of soundness has not been rebutted. As such, the Board will proceed under the premise that his low back disorder did not preexist service. Service treatment records reflect that the Veteran was treated in March 1970 for lumbar flank pain. The clinical impression was mild lumbosacral strain. There is no additional treatment for his back mentioned in the service treatment records. At the time of service separation a year and a half later, the clinical evaluation of his spine was normal. Although the Board acknowledges that he sought treatment for low back pain on one occasion during service, based on the absence of additional complaints during service and a normal separation examination, a chronic back disorder was not shown in service. Next, post-service evidence does not reflect complaints or treatment for a back disorder until a January 1994 private treatment record, over twenty years following separation from service. He was diagnosed with back pain. Therefore, the competent evidence does not reflect continuity of symptomatology. In addition to the absence of documented post-service symptomatology related to his low back for many years, the evidence includes the Veteran and his wife's statements asserting continuity of symptoms with respect to this disorder. The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He has indicated that he continued to experience symptoms relating to his low back after he was discharged from the service. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). In this case, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. The Board again notes that the separation examination was normal, indicating that a spine disorder was not present at that time. Such objective evidence is more reliable than the Veteran's subjective observations. The Board also emphasizes the multi-year gap between discharge from active duty service (1971) and initial reported symptoms related to his low back in approximately 1994 (over a 20-year gap). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). Additionally, the Board has considered that when the Veteran sought to establish medical care with the private physician in January 1994, he did not report that his low back symptomatology was related to an in-service injury or that it was of longstanding duration. Rather, he reported that he had hurt his back after lifting a tar bucket at home. He did not claim that his disorder was related to service until he filed his claim. The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for benefits to be of lesser probative value. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements). Therefore, continuity has not here been established, either through the competent evidence or through his statements. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's low back disorder to active duty. To that end, the Board places significant probative value on a June 2007 VA medical opinion undertaken to specifically address the Veteran's low back claim. The June 2007 VA examiner noted that the Veteran had experienced an episode of lumbar flank pain during service, in March 1970, and was diagnosed with a mild lumbosacral strain. The VA examiner further considered a November 2006 VA examination. He opined that it was his professional opinion that the Veteran's lumbar spine disorder, diagnosed as degenerative disc disease and degenerative spondyloarthritis of the lumbar spine, was less likely than not related to his mild lumbosacral strain reported in March 1970. The Board finds that the June 2007 opinion is adequate for evaluation purposes. Specifically, the examiner reviewed the claims file. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, there is no contradicting medical evidence of record. Therefore, the Board finds the VA examiner's opinion to be of great probative value. The Board has also considered the Veteran and his wife's statements asserting a nexus between his currently-diagnosed low back disorder, and active duty service. Although the Veteran and his wife are competent to report that he had back pain since service, he is not competent to render a medical opinion. Moreover, the Board finds that the June 2007 VA examiner's opinion is the most probative evidence of record. This is because he reviewed his records and considered his reported history. As such, the preponderance of the evidence weighs against a finding that the Veteran's low back disorder developed in service or is due to any event or injury in service. Next, the Board has considered whether presumptive service connection for chronic disease is warranted. Under 38 C.F.R. § 3.309(a), arthritis is regarded as a chronic disease. However, in order to trigger the presumption, such disease must become manifest to a degree of 10 percent or more within 1 year from the date of separation from service. See 38 C.F.R. § 3.307(a)(3). As the evidence of record fails to establish any clinical manifestations of arthritis of his back within the applicable time period, the criteria for presumptive service connection on the basis of a chronic disease have not been satisfied. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. III. VCAA Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran's increased rating claim for PTSD arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. As to VA's duty to assist, the RO associated the Veteran's private treatment records, and he was afforded VA examinations in November 2006 and January 2009. The Board finds that no additional assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). With respect to his service connection claim for a low back disorder, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in June and August 2006 that fully addressed all notice elements and were sent prior to the initial RO decision in this matter. The letters informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. With respect to the Dingess requirements, in June 2006, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the Veteran submitted private treatment records. Next, a VA examination was completed in November 2006, and a VA medical opinion was obtained in June 2007 pertinent to the issue on appeal. Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating in excess of 70 percent for PTSD is denied. Service connection for a low back disorder, claimed as degenerative disc disease and degenerative spondyloarthritis of the lumbar spine, is denied. REMAND The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). The Board finds that additional development is required in order to satisfy VA's obligations under the VCAA. Cervical Spine-The Veteran indicated, in his August 2008 substantive appeal, that he had had recent surgery on his neck. Although a July 2008 letter from the South Florida Spine Clinic briefly summarizes the operation, it appears that there are additional treatment records which have not yet been associated with the claims file. As such, all available records associated with the Veteran's cervical spine, from the South Florida Spine Clinic, should be obtained on remand. Actinic Keratosis- VA's duty to assist includes a duty to obtain a medical opinion when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2009). The Veteran has proffered three alternative causes for his actinic keratosis. He first contends that he has this skin disorder due to herbicide exposure during service. Alternative causes for his skin disorder were raised at an October 2006 VA examination. He indicated that he was repeatedly sunburned during his service, in Vietnam, without the benefit of sunscreen. He additionally stated that he was the hauler for JP-4 jet fuel that serviced choppers and jets, which frequently resulted in spills on his arms, legs, and hands. Although the Veteran contends that his skin disorder is associated with exposure to herbicides, the Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 57586-57589 (1996). Thus, service connection for his skin disorder, as evaluated under the regulations governing presumptive service connection based on exposure to Agent Orange, is not warranted. The Veteran has additionally indicated that his skin disorder may be the result of both sunburns and/or exposure to jet fuel. Although an October 2006 VA skin examination was undertaken, a VA medical opinion was not obtained. It is unclear from the claims file whether the etiology of this disorder is associated with his alleged in-service causes. The Board finds these are medical questions outside of its jurisdiction. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). As such, a VA examination is required to determine the etiology of the Veteran's skin disorder. Accordingly, the case is REMANDED for the following actions: 1. After obtaining the appropriate releases, obtain all available records from the South Florida Spine Clinic regarding treatment of the Veteran's cervical spine. Any negative search result should be noted in the record. 2. Schedule the Veteran for an appropriate examination to assess his skin disorder and evaluate the relationship between his skin disorder and active duty service. The examiner is asked to provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent) that his skin disorder is causally related to service. Any opinion offered should be accompanied by a clear rationale consistent with the evidence of record. The claims file must be reviewed in conjunction with the examination. The examiner must indicate in the examination report that the claims file was reviewed. 3. Upon completion of the above, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp.2009). ______________________________________________ MICHAEL MARTIN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs