Citation Nr: 1307371 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 10-26 383 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial evaluation of 40 percent for a low back disorder from March 28, 2007, to January 25, 2010. 2. Entitlement to service connection for a bilateral hip disorder. 3. Entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for a psychiatric disorder. 5. Entitlement to service connection for a skin disorder including chloracne. 6. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Allen Gumphenberger, Agent ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran had active service from October 1965 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2005, June 2009, and May 2010 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in Atlanta, Georgia. As to the rating claim, in the Veteran's June 2010 notice of disagreement he specifically notified the RO that he was only expressing dissatisfaction with the May 2010 rating decision to the extent that it failed to grant him a 40 percent rating for his newly service connected low back disorder effective from the date it granted service connection (i.e., March 28, 2007) but instead granted him a 20 percent rating for this first time period that ran from March 28, 2007, to January 25, 2010. Therefore, in order to reflect the Veteran's true intent when filing the current appeal the Board has recharacterized this issue as it appears on the first page of the decision. See Hamilton v. Brown, 4 Vet. App. 528 (1993) ("where ... the claimant expressly indicates an intent that adjudication of certain specific claims not proceed at a certain point in time, neither the RO nor BVA has authority to adjudicate those specific claims, absent a subsequent request or authorization from the claimant or his or her representative"). As to the claims of service connection for a bilateral hip disorder, a cervical spine disorder, and a psychiatric disorder the Board notes that the RO treated these issues as claims to reopen arising from appeals of August 2007 and June 2009 rating decisions. However, the Board's review of the record on appeal reveals that the Veteran filed a timely notice of disagreement in July 2005 to the April 2005 rating decision that first denied these claims. See 38 C.F.R. § 20.201 (2012); Fenderson v. West, 12 Vet. App. 119 (1999) (holding that the Board determines de novo whether a document is a notice of disagreement). Therefore, the Board has also recharacterized these issues as they appear on the first page of the decision. The claims of service connection for a bilateral hip disorder, a cervical spine disorder, a psychiatric disorder, and a skin disorder as well as the claim for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDING OF FACT From March 28, 2007, to January 25, 2010, the most competent and credible evidence of record did not show that the Veteran's low back disability was manifested by incapacitating episodes that required bed rest prescribed by a physician and treatment by a physician having a total duration of at least 4 weeks during any 12 month period during this time; forward flexion of the thoracolumbar spine limited to 30 degrees or less even taking into account his complaints of pain; favorable ankylosis of the entire thoracolumbar spine; or radiculopathy with at least mild incomplete paralysis of the sciatic nerve. CONCLUSION OF LAW From March 28, 2007, to January 25, 2010, the Veteran did not meet the criteria for a 40 percent for his low back disability. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, 4.123, 4.124, 4.124a, Diagnostic Codes 5235 to 5243 and 8520 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). Initially, the Board finds that there is no issue as to whether the Veteran was provided an appropriate application form or issue as to whether the claimant has veteran status. Next, the Board notes that the Veteran is challenging the initial evaluation assigned following the grant of service connection for his low back disability. In Dingess, supra, the Court also held that in cases where service connection has been granted and an initial disability evaluation has been assigned, the service connection claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id, at 490-91; Also see Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, regardless of whether the notice that the Veteran was provided with before service connection was granted was legally sufficient, the Board finds that VA's duty to notify in this case has been satisfied. Moreover, the Board finds that even if VA had an obligation to provide notice under 38 U.S.C.A. § 5103(a) and failed to do so, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the May 2010 rating decision and the February 2012 statement of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). As to the duty to assist, the Board finds that VA has secured all identified, available, and identified pertinent in-service and post-service evidence including the Veteran's service treatment records and post-service records from the Nashville VA Medical Center. The Veteran was also afforded a VA examination in March 2006 which the Board finds is adequate for rating purposes because the examiners, after a review of the Veteran's medical records, taking a detailed medical history from the claimant, and after a comprehensive examination, provided a medical opinion as to the severity of his disorder that allows the Board to rate it under all applicable rating criteria. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007). In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claim below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims files shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Claim The Veteran asserts that his low back disability met the criteria for a 40 percent rating from March 28, 2007, to January 25, 2010. It is also requested that the Veteran be afforded the benefit of the doubt. 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.A. § 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). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate 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 Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this regard, regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. In the May 2010 rating decision, the RO granted service connection for the low back disability and rated it as 20 percent disabling from March 28, 2007, to January 25, 2010, and 40 percent disabling from January 26, 2010, under 38 U.S.C.A. § 4.71a, Diagnostic Code 5243. As explained above, since the Veteran has limited his appeal to the question of whether he met the criteria for a 40 percent rating for his low back disability from March 28, 2007, to January 25, 2010, the Board will likewise limits its adjudication to this question. See Hamilton, supra. The Formula for Rating Intervertebral Disc Syndrome provides a rating in excess of 20 percent, only if the Veteran's adverse symptomatology includes incapacitating episodes having a total duration of at least 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Diagnostic Code 5243 defines an incapacitating episode as one where the Veteran has physician prescribed bed rest. Id. The General Rating Formula for Disease and Injuries of the Spine provides a higher, 40 percent rating, only if forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5242. Note (1) also articulates that neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Id. When evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id, at 206. Under 38 C.F.R. § 4.40, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. Additionally, 38 C.F.R. § 4.45 provides, as regards to the joints, that the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the spine is considered a major joint. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), the Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). As to rating the Veteran's low back disability under the Formula for Rating Intervertebral Disc Syndrome, the Veteran and his representative claim, in substance, that the appellant's adverse symptomatology causes him to require bed rest for two to three days as often as eight times a month. See, for example, the Veteran's claims to the March 2006 VA examiner. However, the Board finds that there is no competent and credible evidence in the record of the claimant's low back disability requiring physician prescribed bed rest for at least 4 weeks at any time during this time period. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Consequently, the Board finds that the Veteran did not meet the criteria for a 40 percent evaluation for his low back disability under the Formula for Rating Intervertebral Disc Syndrome. Id. This is true from March 28, 2007, to January 25, 2010, and therefore consideration of further staged ratings on this basis is also not warranted. Fenderson, supra. As to rating the Veteran's low back disability under the General Rating Formula for Disease and Injuries of the Spine due to ankylosis, the Board notes that the Veteran's claims file does not contain a diagnosis of ankylosis of the lumbosacral spine. (Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). In fact, the March 2006 VA examiner specifically opined that he did not have ankylosis of the lumbosacral spine and this opinion is not contradicted by any other medical opinion of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). In the absence of ankylosis, the Board may not rate his service-connected low back disability as ankylosis. Johnston v. Brown, 10 Vet. App. 80 (1997). Consequently, the Board finds that the Veteran did not meet the criteria for a 40 percent evaluation for his low back disability under this part of the General Rating Formula for Disease and Injuries of the Spine. 38 C.F.R. § 4.71a. This is true from March 28, 2007, to January 25, 2010, and therefore consideration of further staged ratings on this basis is also not warranted. Fenderson, supra. As to rating the Veteran's low back disability under the General Rating Formula for Disease and Injuries of the Spine due to lost flexion, at the March 2006 VA examination, the pain free range of motion of the lumbosacral spine after repetition was flexion to 50 degrees. While a review of the record on appeal for the March 28, 2007, to January 25, 2010, time period reveals treatment records that documented the Veteran's complaints and treatment for low back pain with lost motion being treated with steroid injections, nothing in these records show the appellant's lost flexion worse than what was reported by the March 2006 VA examiner. See Colvin, supra. Therefore, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca, supra, that the Veteran's functional losses do not equate to the criteria required for a 40 percent rating for his low back disability because, at its worst, forward flexion of the thoracolumbar spine was 50 degrees (not 30 degrees or less). 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. Consequently, the Board finds that the Veteran did not meet the criteria for a 40 percent evaluation for his low back disability under this part of the General Rating Formula for Disease and Injuries of the Spine. 38 C.F.R. § 4.71a. This is true from March 28, 2007, to January 25, 2010, and therefore consideration of further staged ratings on this basis is also not warranted. Fenderson, supra. Radiculopathy Given the scope of the Veteran's service connected spine disability, the complaints made by the Veteran regarding radiating pain, the Court's holding in Esteban, supra, and Note 1 to 38 C.F.R. § 4.71a that allows the claimant to receive separate compensable ratings for adverse neurological symptomatology associated with his service connected low back disability, the Board will next consider if he meets the criteria for a separate compensable rating for radiculopathy at any time from March 28, 2007, to January 25, 2010. In this regard, 38 C.F.R. § 4.124a, Diagnostic Code 8516 provides a 10 percent rating for mild incomplete paralysis of the ulnar nerve in either the major or minor upper extremity. Similarly, 38 C.F.R. § 4.124a, Diagnostic Code 8520 provides a 10 percent rating for mild incomplete paralysis of the sciatic nerve in either lower extremity. 38 C.F.R. § 4.124a defines the term "incomplete paralysis" as indicating a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.123 provides that neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.124 provides that neuralgia, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. At the March 2006 VA examination, neurological examination of the lower extremities revealed muscle and sensory function within normal limits with reflexes at 3+ in the knees and ankles. On examination, the Veteran did not complain of radiating pain with range of motion studies and he did not have muscle spasms. While a review of the record on appeal for the March 28, 2007, to January 25, 2010, time period reveals treatment records that documented the Veteran's complaints regarding low back pain with pain radiating down both legs diagnosed as peripheral neuropathy, nothing in these records show the appellant's adverse neurological symptomatology worse than what was reported by the March 2006 VA examiner. See Colvin, supra. Given the above record, which is negative for any objective evidence of adverse neurological symptomatology despite the diagnosis of peripheral neuropathy seen in the VA treatment records, the Board finds that the adverse symptomatology attributable to the service connected low back disability does not equate to at least moderately incomplete paralysis of the sciatic nerve in either lower extremity. 38 C.F.R. § 4.124a. Therefore, the Board finds that a separate compensable rating for adverse neurological symptomatology caused by the claimant's service connected low back disability is not warranted. This is true from March 28, 2007, to January 25, 2010, and therefore consideration of further staged ratings on this basis is also not warranted. Fenderson, supra. Other Back Concerns Lastly, the Board notes that each of the ways by which the thoracolumbar spine is ratable, other than some of those described in 38 C.F.R. § 4.71a, Diagnostic Code 5243, contemplates limitation of motion. Also see VAOPGCPREC 36-97; 63 Fed. Reg. 31262 (1998). Therefore, assigning separate ratings on the basis of both a strain and other symptoms, such as those set forth in Diagnostic Code 5242, would be inappropriate. 38 C.F.R. § 4.14. Extraschedular Ratings As to the Veteran's claim that his disability is worse than rated, under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluations for the disability is inadequate (which they are manifestly not), the Veteran does not exhibit other related factors such as those provided by the regulations as "governing norms." Specifically, there simply is no objective evidence that the above disability resulted in marked interference with employment or frequent periods of hospitalization. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In fact, the March 2006 VA examiner specifically opined that the Veteran's low back disability only had a minimal affect on his employment. Therefore, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that the service-connected disability causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) was not warranted for the March 28, 2007, to January 25, 2010, time period. Fenderson, supra. In reaching the above conclusions, the Board has not overlooked the various lay statements found in the record. In this regard, the Veteran is credible to report on what he sees and feels such as pain and lost motion and the claimant and others are credible to report on what they can see. See Davidson, supra; Buchanan, supra; Jandreau, supra; Charles, supra. However, the Board finds more competent and credible the medical opinions as to the severity of the disability provided by the experts at the VA examination than these lay assertions. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."). Conclusion The Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim the doctrine is not for application. 38 U.S.C.A. § 5107(b); See also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a 40 percent rating for a low back disability is denied at all times from March 28, 2007, to January 25, 2010. REMAND As to the claims of service connection for a bilateral hip disorder, a cervical spine disorder, and a psychiatric disorder, the Veteran claims that these disorders were either caused by the same 1967 fuel tank accident in which he injured his knees and/or were caused or aggravated by his service connected bilateral knee and/or low back disabilities. Moreover, the RO provided the Veteran with VA examinations in January 2005, March 2006, January 2010, and/or June 2011 to obtain medical opinions as to the origins or etiology of these disorders. However, the Board finds the opinions to be inadequate. As to claim of service connection for a bilateral hip disorder, the Board has reached this conclusion because the March 2006 examiner did not provide a medical opinion as to direct causation or as to whether his bilateral hip disorder was aggravated by his service connected bilateral knee disabilities. See 38 C.F.R. § 3.310; 38 C.F.R. § 3.303; Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein); Also see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (holding that compensation is payable when service-connected disability has aggravated a non-service-connected disorder). As to claim of service connection for a cervical spine disorder, the Board has reached this conclusion because the January 2010 examiner did not provide a medical opinion as to direct causation. 38 C.F.R. § 3.303; Rabideau, supra. As to claim of service connection for a psychiatric disorder, the Board has reached this conclusion because the January 2005 examiner did not provide a medical opinion as to causation and the June 2011 examiner did not provide a medical opinion as to direct causation and applied the wrong legal standard (i.e., "clear and unmistakable evidence" and not "at least as likely as not") as to secondary service connection. See 38 C.F.R. § 3.310; 38 C.F.R. § 3.303; Rabideau, supra; Allen, supra. Therefore, the Board finds that a remand to obtain adequate medial opinions is required. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to claim of service connection for a skin disorder, the Veteran's DD 214 lists his occupational specialty as fuel specialist. Moreover, the Board finds that the Veteran is competent to both report on what he sees and feels while on active duty and since that time even when not documented in his medical records, including seeing 55 gallon drums that he was told were full of herbicides be loaded on to aircraft and having itchy and red skin while on active duty since being exposed to what was in those drums as well as since being exposed to fuel, because these things come to him from his senses. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Furthermore, the post-service record is positive for complaints and treatment for various skins disorders including chloracne since approximately 2002. Given this history, the Board finds that a remand is required to obtain a medical opinion as to the relationship between the Veteran's post-service skin disorders and his military service. See 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran appears to receive ongoing care at the Nashville VA Medical Center. However, his post-May 2010 treatment records from this facility are not in the claims file. Therefore, while the appeal is in remand status the RO/AMC should also obtain and associate with the claims file his post-May 2010 treatment records from this facility. See 38 U.S.C.A. § 5103A(b); Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA adjudicators are deemed to have constructive notice of VA treatment records). As to the claim for a TDIU, the Board finds that it is inextricably intertwined with the above issues. Therefore, the Board finds that adjudication of the TDIU claim must be held in abeyance until the RO carries out the above development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Accordingly, these issues are REMANDED to the RO for the following actions: 1. The RO shall obtain and associate with the record the Veteran's post-May 2010 treatment records from the Nashville VA Medical Center. All actions to obtain the requested records should be documented fully in the claims file. 2. After undertaking the above development to the extent possible, the RO shall provide the Veteran with an orthopedic examination to ascertain the origins of his bilateral hip disorder and cervical spine disorder. The claims file must be provided to the examiner in connection with the examination. The examiner shall conduct all indicated tests and studies including X-rays and all clinical findings should be reported in detail. After a review of the record on appeal and an examination of the claimant, the examiner is directed to provide answers to the following questions: a. What are the diagnoses of all of the Veteran's hip and cervical spine disorders? b. As to each diagnosed hip and cervical spine disorder, is it at least as likely as not (50 percent probability or more) that it was caused by active service or has continued since active service? c. As to any arthritis of either hip and/or the cervical spine, is it at least as likely as not (50 percent probability or more) that it manifested itself to a compensable degree in the first post-service year? d. As to each diagnosed hip and cervical spine disorder, is it at least as likely as not (50 percent probability or more) that it was caused by any of the Veteran's service connected disabilities including his bilateral knee disabilities and low back disability? e. As to each diagnosed hip and cervical spine disorder, is it at least as likely as not (50 percent probability or more) that it is aggravated by any of the Veteran's service connected disabilities including his bilateral knee disabilities and low back disability? In providing answers to the above questions, the examiner must comment on and/or take note of the fact that the claimant is competent and credible to report on the observable symptom of his disabilities (i.e., pain, limitation of motion, and swelling, etc . . .) while on active duty and since that time even when not documented in his medical records. In providing answers to the above questions, the examiner is advised that he cannot rely solely on negative evidence such as service treatment records being negative for the claimed disorder. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim). If the examiner cannot provide an answer to any of the above questions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed such as additional records and/or diagnostic studies). If the examiner cannot provide the answer because further information to assist in making the determination is needed, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. In providing answers to the above questions, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. In providing answers to the above questions, the examiner is advised that the term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent that is possible, the approximate level of disability (i.e., a baseline) before the onset of the aggravation. A complete rationale with citation to relevant evidence found in the claims file should be provided for each opinion offered. 3. After undertaking the development set out in paragraph 1 above to the extent possible, the RO shall provide the Veteran with a psychiatric examination. The claims file must be provided to the examiner in connection with the examination. The examiner shall conduct all indicated tests and studies. After a review of the record on appeal and an examination of the claimant, the examiner is directed to provide answers to the following questions: a. What are the diagnoses of all of the Veteran's psychiatric disorders? b. As to each diagnosed psychiatric disorder, is it at least as likely as not (50 percent probability or more) that it was caused by active service or has continued since active service? c. As to any psychosis, is it at least as likely as not (50 percent probability or more) that it manifested itself to a compensable degree in the first post-service year? d. As to each diagnosed psychiatric disorder, is it at least as likely as not (50 percent probability or more) that it was caused by any of the Veteran's service connected disabilities including the pain caused by his bilateral knee disabilities and low back disability? e. As to each diagnosed psychiatric disorder, is it at least as likely as not (50 percent probability or more) that it is aggravated by any of the Veteran's service connected disabilities including the pain caused by his bilateral knee disabilities and low back disability? In providing answers to the above questions, the examiner must comment on and/or take note of the fact that the claimant is competent and credible to report on the observable symptom of his disability while on active duty and since that time even when not documented in his medical records. In providing answers to the above questions, the examiner is advised that he cannot rely solely on negative evidence such as service treatment records being negative for the claimed disorder. See Dalton, supra. If the examiner cannot provide an answer to any of the above questions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed such as additional records and/or diagnostic studies). If the examiner cannot provide the answer because further information to assist in making the determination is needed, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. In providing answers to the above questions, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. In providing answers to the above questions, the examiner is advised that the term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent that is possible, the approximate level of disability (i.e., a baseline) before the onset of the aggravation. A complete rationale with citation to relevant evidence found in the claims file should be provided for each opinion offered. 4. After undertaking the development set out in paragraph 1 above to the extent possible, the RO shall provide the Veteran with a dermatological examination. The claims file must be provided to the examiner in connection with the examination. The examiner shall conduct all indicated tests and studies. After a review of the record on appeal and an examination of the claimant, the examiner is directed to provide answers to the following questions: a. What are the diagnoses of all of the Veteran's skin disorders? b. As to each diagnosed skin disorder, is it at least as likely as not (50 percent probability or more) that it was caused by active service or has continued since active service? In providing answers to the above questions, the examiner must comment on and/or take note of the fact that the claimant is competent and credible to report on the observable symptom of his skin disorder (i.e., red and itchy skin) while on active duty and since that time even when not documented in his medical records; the Veteran's occupational specialty was fuel specialist; and he is competent to report on report what he saw such as seeing 55 gallon barrels of what he was told were herbicides being loaded onto aircraft. In providing answers to the above questions, the examiner is advised that he cannot rely solely on negative evidence such as service treatment records being negative for the claimed disorder. See Dalton, supra. If the examiner cannot provide an answer to any of the above questions, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed such as additional records and/or diagnostic studies). If the examiner cannot provide the answer because further information to assist in making the determination is needed, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. In providing answers to the above questions, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. A complete rationale with citation to relevant evidence found in the claims file should be provided for each opinion offered. 5. After undertaking the development set out in paragraph 1 above to the extent possible, the RO shall provide the Veteran with a TDIU examination. The claims file must be provided to the examiner in connection with the examination. The examiner shall conduct all indicated tests and studies. After a review of the record on appeal and an examination of the claimant, the examiner is directed to provide an answer to the following question: Is it at least as likely as not that the Veteran's service connected disabilities prevent him from engaging in substantially gainful employment. In providing an answer to the above question, the examiner is instructed to ignore the effects of age or any non-service connected disabilities. In providing an answer to the above question, the examiner must comment on and/or take note of the fact that the claimant is competent and credible to report on the observable symptom of his service connected disorders. If the examiner cannot provide an answer to the above question, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed such as additional records and/or diagnostic studies). If the examiner cannot provide the answer because further information to assist in making the determination is needed, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. In providing an answer to the above question, the examiner is advised that the term at least as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship; less likely weighs against the claim. A complete rationale with citation to relevant evidence found in the claims file should be provided for each opinion offered. 6. The RO should thereafter readjudicate the claims. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claims for benefit since the February 2012 statement of the case, and any evidence not received, and all applicable laws and regulations considered pertinent to the issues currently on appeal including 38 C.F.R. § 3.310. A reasonable period of time should be allowed for response before the appeal is returned to the Board. The appellant and his representative have 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ G. A. Wasik Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs