Citation Nr: 1328568 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 10-26 486 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for pharyngitis. 2. Entitlement to service connection for bilateral Achilles tendonitis. 3. Entitlement to service connection for eczema of the lower extremities. 4. Entitlement to service connection for sinusitis. 5. Entitlement to service connection for a duodenal ulcer. 6. Entitlement to a disability evaluation in excess of 10 percent for a right knee disability. 7. Entitlement to a compensable disability evaluation for gastroesophageal reflux disease (GERD). 8. Entitlement to service connection for disability evaluation in excess of 30 percent for depression prior to May 29, 2013, and in excess of 70 percent thereafter. 9. Whether the reduction from 10 percent to a noncompensable rating for a forehead scar, beginning October 29, 2008, was proper. ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from September 1983 to July 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, and a March 2010 rating decision of the VA RO in San Juan, the Commonwealth of Puerto Rico. The March 2009 rating decision denied the Veteran's petitions to reopen claims for service connection and his claims for increased evaluations. It also reduced his disability evaluation for his forehead scar from 10 percent to noncompensable. The March 2010 rating decision continued the Veteran's 30 percent evaluation for an acquired psychiatric disorder. The Veteran frequently moved between St. Petersburg and San Juan. The St. Petersburg RO currently has jurisdiction over his claims file. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. In May 2013 the Board remanded this case to the RO via the Appeals Management Center (AMC) for further development and it has now been returned to the Board. In a June 2013 rating decision, the RO increased the Veteran's evaluation for depression from 30 percent to 70 percent, effective May 29, 2013. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). In May 2013, the Veteran submitted additional VA medical records from 1987 to 2001 and duplicate STRs. Some of the medical evidence is duplicative of evidence already in his claims file. Further, the VA treatment records terminate prior to the start of the appeal period. Lastly, in June 2013, the Veteran's representative submitted a waiver of initial RO consideration of additional evidence. 38 C.F.R. §§ 20.800, 20.1304(c) (2012). In July 2013, the Veteran submitted a private medical opinion from Dr. J. G. pertaining to his sinusitis claim. It was accompanied by a waiver of initial RO consideration. Id. The issues of entitlement to service connection for eczema of the legs and bilateral Achilles tendonitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC. The issues of entitlement to service connection for headaches, a low back disability, and hypertension were raised by the record in a July 2013 statement from Dr. J. G., but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran does not have pharyngitis due to any incident of his active duty service. 2. The preponderance of the evidence reflects that the Veteran does not have sinusitis due to any incident of his active duty service. 3. The preponderance of the evidence reflects that the Veteran does not have a duodenal ulcer due to any incident of his active duty service. 4. The Veteran's right knee disability manifests as limitation of flexion to 90 degrees and mild degenerative joint disease (DJD) shown on x-ray with painful motion. 5. The Veteran's GERD manifests as epigastric distress after meals due to pyrosis with right shoulder pain. 6. In July 2013, prior to the promulgation of a decision on the issue of entitlement to a disability evaluation in excess of 30 percent for depression prior to May 29, 2013 and in excess of 70 percent thereafter, the Veteran, through his representative, withdrew his appeal. 7. At the time of the reduction of the Veteran's rating for a forehead scar, his scar was tender and painful to touch. CONCLUSIONS OF LAW 1. Pharyngitis was not incurred or aggravated in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. Sinusitis was not incurred or aggravated in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. A duodenal ulcer was not incurred or aggravated in service and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 4. The criteria for a disability evaluation in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.20, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5256-5263 (2012). 5. The criteria for a 10 percent evaluation for GERD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7346 (2012). 6. The criteria for withdrawal of the Veteran's appealed claim for entitlement to a disability evaluation in excess of 30 percent for depression prior to May 29, 2013 and in excess of 70 percent thereafter have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 7. The preponderance of the evidence demonstrates that the reduction in rating from 10 percent to noncompensable for the Veteran's forehead scar was not proper. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.105(e), 4.118, Diagnostic Code 7804 (2007 & 2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist 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 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA has satisfied its duty to notify by issuing pre- adjudication letters in October 2008 and January 2009 for the March 2009 rating decision and in and June 2009 for the March 2010 rating decision. The letters advised the Veteran of what evidence was required to substantiate his claims, and of his and VA's respective duties for obtaining evidence. The January 2009 and June 2009 letters provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, and reports of VA examinations for scars and joints in October 2008 and all of the issues listed above in May 2013. The examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. With regard to the Veteran's service connection claims, the examiner also provided rationales for the opinions. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). With regard to the reduction of the Veteran's forehead scar rating, the duties to notify and assist do not apply where the issue is a reduction in rating. In the case of a reduction, there has been no application or claim, so the VCAA is inapplicable. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b), (c). Given that the Board is restoring the Veteran's 10 percent evaluation for his scar, any further development or notification action as required by the specific notice requirements which apply to a reduction in rating is not required. 38 C.F.R. § 3.105(e). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). II. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a),(b), 3.309(a); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Certain chronic diseases, including peptic ulcer disease, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; see also Walker, supra. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). A. Pharyngitis The Veteran's VA treatment records do not show a diagnosis of or treatment for pharyngitis during the appeal period. An August 2006 VA examination noted that he had pharyngitis in March 1994 and December 1995. His nasal examination was normal and he was not diagnosed with pharyngitis in August 2006. He also did not have pharyngitis at his May 2013 examination. The examiner specifically stated that the Veteran did not have chronic pharyngitis. The examination reports provide probative evidence against a finding that the Veteran has chronic pharyngitis. In October 2008, Dr. J. G., the Veteran's private physician, stated that the Veteran had been a patient since March 1994 and received treatment for recurrent pharyngitis. However, the records from Dr. J. G. from 1994 to 2006 fall outside the appeal period. Aside from Dr. J. G.'s statement in October 2008, the evidence of record does not show that the Veteran has been diagnosed with or treated for pharyngitis during the appeal period. The Board finds that the preponderance of the evidence is against a finding that the Veteran has had pharyngitis during the appeal period. 38 U.S.C.A. § 5107(b). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see McClain v. Nicholson, 21 Vet. App. 319 (2007) (finding that the requirement for a current disability is satisfied if the claimant has a disability at the time a claim was filed or at any time during the pendency of the appeal, even if the disability resolves prior to the Secretary's adjudication of the claim). The first element of a service connection claim is not satisfied. Hickson, 12 Vet. App. at 253. The Veteran's STRs show that he was treated for an episode of pharyngitis in 1985, satisfying the second element of a service connection claim. Id. Even if the Veteran had chronic pharyngitis during the appeal period, the evidence does not support a nexus between that condition and service. At his May 2013 VA examination, the examiner noted that the Veteran's STRs show one episode of pharyngitis in 1985. The examiner concluded that the Veteran did not have chronic pharyngitis, and that the claimed condition was not related to service. He explained that "[p]haryngitis is usually an acute illness, not a chronic disability." The examiner's opinion provides probative evidence against a nexus between the claimed condition and service. In October 2008, Dr. J. G. stated that the Veteran's pharyngitis "could have been or originated or are a possible consequence" of active service. Speculative language such as "could have been" and "possible consequence" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). Dr. J. G.'s opinion is not probative evidence. The Veteran submitted lay statements in support of his service connection claims but did not advance an argument other than that he believes the claimed conditions originated in the military. The Board finds his statements competent and credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, they are not specific to his claims and are not probative. The first and third elements of a service connection claim are not satisfied. Hickson, 12 Vet. App. at 253. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim for service connection for pharyngitis must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). B. Sinusitis The Veteran's VA treatment records do not show a diagnosis of or treatment for sinusitis during the appeal period. A March 2007 VA treatment record noted an episode of acute sinusitis. An x-ray showed enlarged nasal turbinates mucosa but the paranasal sinuses were clear. An October 2012 MRI of the Veteran's head was negative for sinusitis. He also did not have sinusitis at his May 2013 examination. The examiner specifically stated that the Veteran did not have chronic sinusitis. The examination reports provide probative evidence against a finding that the Veteran has chronic sinusitis. In October 2008, Dr. J. G., the Veteran's private physician, stated that the Veteran had been a patient since March 1994 and received treatment for recurrent sinusitis. However, the records from Dr. J.G. from 1994 to 2006 fall outside the appeal period. Aside from Dr. J. G.'s statement in October 2008, the evidence of record does not show that the Veteran has been diagnosed with or treated for sinusitis during the appeal period. The Board finds that the preponderance of the evidence is against a finding that the Veteran has had sinusitis during the appeal period. 38 U.S.C.A. § 5107(b). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich, 104 F. 3d at 1328. In the absence of evidence of a current disability there can be no valid claim. Brammer, 3 Vet. App. at 225; see McClain v. Nicholson, 21 Vet. App. at 319. The first element of a service connection claim is not satisfied. Hickson, 12 Vet. App. at 253. The Veteran's STRs show that he was treated for an episode of sinusitis in 1985, satisfying the second element of a service connection claim. Id. Even if the Veteran had chronic sinusitis during the appeal period, the evidence does not support a nexus between that condition and service. At his May 2013 VA examination, the examiner noted that the Veteran's STRs show one episode of sinusitis in 1985. The examiner concluded that the Veteran did not have chronic sinusitis, and that the claimed condition was not related to service. Further, the Veteran did not have sinusitis at the exam and had not had an episode since 2007. The examiner's opinion provides probative evidence against a nexus between the claimed condition and service. In October 2008, Dr. J. G. stated that the Veteran's sinusitis "could have been or originated or are a possible consequence" of active service. Speculative language such as "could have been" and "possible consequence" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren, 6 Vet. App. at 6; Utendahl, 1 Vet. App. at 531; Stegman, 3 Vet. App. at 230; Obert, 5 Vet. App. at 33. Dr. J. G.'s opinion is not probative evidence. Similarly, in July 2013, Dr. J. G. stated that the Veteran's sinusitis was due to exposure to dirt and dust particles. He explained that sinusitis "usually" is caused by an allergy to dust particles and dirt "although there are other conditions which may cause" sinusitis. Dr. J. G. concluded that the Veteran's sinusitis "can be" related to his period of active service because he was around vehicles while on active duty. Speculative language such as "may cause" and "can be" are also speculative and therefore the opinion is not probative evidence. Id. The Veteran submitted lay statements in support of his service connection claims but did not advance an argument other than that he believes the claimed conditions originated in the military. The Board finds his statements competent and credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, they are not specific to his claims and are not probative. The first and third elements of a service connection claim are not satisfied. Hickson, 12 Vet. App. at 253. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim for service connection for sinusitis must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). C. Duodenal Ulcer The Veteran's VA treatment records do not show a diagnosis of or treatment for a duodenal ulcer. He did not have a duodenal ulcer at his May 2013 examination. The examiner specifically stated that the Veteran did not have a duodenal ulcer, instead the examiner diagnosed gastritis and gastroduodenitis, which the Veteran had in 2009. The examiner noted that the Veteran was not treated for either gastritis or gastroduodenitis in service. One STR noted that a duodenal ulcer was suspected, but it was never diagnosed. Instead, he had an episode of gastroenteritis in service in 1986 but it resolved. The examiner explained that "[g]astroenteritis is usually acute and not a chronic condition." The examination reports provide probative evidence against a finding that the Veteran has chronic sinusitis. In October 2008, Dr. J. G. stated that the Veteran's VA medical records showed that he had a duodenal ulcer, but did not state that he treated the Veteran for this condition. The Veteran's VA treatment records do not reflect a diagnosis of or treatment for a duodenal ulcer during the appeal period. Aside from Dr. J. G.'s statement in October 2008, the evidence of record does not show that the Veteran has been diagnosed with or treated for a duodenal ulcer during the appeal period. The Board finds that the preponderance of the evidence is against a finding that the Veteran has had a duodenal ulcer prior to or during the appeal period. 38 U.S.C.A. § 5107(b). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich, 104 F. 3d at 1328. In the absence of evidence of a current disability there can be no valid claim. Brammer, 3 Vet. App. at 225; see McClain v. Nicholson, 21 Vet. App. at 319. The first element of a service connection claim is not satisfied. Hickson, 12 Vet. App. at 253. The Veteran's STRs show that he was treated for a single episode of gastroenteritis. A duodenal ulcer was suspected, but not diagnosed. The second element of a service connection claim is not met. Id. Even if the Veteran had a duodenal ulcer during the appeal period, the evidence does not support a nexus between that condition and service. At his May 2013 VA examination, the examiner noted that the Veteran's STRs show one episode of gastroenteritis in 1986. He was not treated for symptoms of or diagnosed with a duodenal ulcer. Further, he has not been treated for or diagnosed with a duodenal ulcer since his separation from service. Regarding gastroenteritis, the examiner found that it is an acute condition, meaning that it resolved. The examiner concluded that the Veteran did not have a duodenal ulcer, and that the claimed condition was not related to service. Further, the Veteran did not have a duodenal ulcer at the exam and had not had an episode since of gastroenteritis 2009. The examiner's opinion provides probative evidence against a nexus between the claimed condition and service. In October 2008, Dr. J. G. stated that the Veteran's claimed duodenal ulcer "could have been or originated or are a possible consequence" of active service. Speculative language such as "could have been" and "possible consequence" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren, 6 Vet. App. at 6; Utendahl, 1 Vet. App. at 531; Stegman, 3 Vet. App. at 230; Obert, 5 Vet. App. at 33. Dr. J. G.'s opinion is not probative evidence. The Veteran submitted lay statements in support of his service connection claims but did not advance an argument other than that he believes the claimed conditions originated in the military. The Board finds his statements competent and credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, they are not specific to his claims and are not probative particularly as to the issue of continuity of symptomatology and especially in light of the absence of evidence of current disability. The three elements of a service connection claim are not satisfied. Hickson, 12 Vet. App. at 253. Since the preponderance of the evidence is against the claim, the provisions of 38 U. S. C. A. 5107(b) regarding reasonable doubt are not applicable, and his claim for service connection for a duodenal ulcer must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). III. Increased Evaluation Claims Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran submitted his claims for increased evaluations in October 2008. "The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The law as to the evaluation of evidence and the standard of proof in veterans' benefits claims is reviewed above and will not be repeated here. A. Right Knee The Veteran's right knee disability is currently evaluated as 10 percent disabling under Diagnostic Code 5299-5260. 38 C.F.R. § 4.71a (2012). The Veteran's right knee status post meniscectomy with residuals is not specifically listed in the rating schedule. An unlisted condition may be rated under the Diagnostic Code for a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. When a disability is not specifically listed, the Diagnostic Code will be "built up," meaning that the first two digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be "99." 38 C.F.R. § 4.27. The most closely analogous Diagnostic Code is 5260, which provides ratings for limitation of flexion of the leg. There are two Diagnostic Codes for limitation of motion of the knee, they provide criteria for limitation of flexion and extension of the leg. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Under Diagnostic Code 5260, limitation of flexion of the leg, a 10 percent evaluation is warranted when flexion of the leg is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. 38 C.F.R. § 4.71a. Normal flexion is 140 degrees. 38 C.F.R. § 4.71a, Plate II. The Veteran underwent a VA examination in October 2008. His flexion was 115 degrees with pain at 110 degrees. After repetitive motion, he had no additional limitation of motion due to pain, weakness, fatigue, incoordination, or lack of endurance. A September 2009 VA treatment report noted knee pain without swelling, crepitus, or erythema. In May 2010, he complained of severe knee pain and was prescribed a low dose of morphine, which did not relieve his symptoms. In May 2013 he underwent a second VA examination. His flexion was 90 degrees with no objective evidence of painful motion. After repetitive motion, he had no additional limitation of motion due to functional loss. He denied flare ups. His strength was normal. He had tenderness to palpation. The remaining medical and lay evidence of record does not address the Veteran's limitation of flexion. The record shows that the Veteran had subjective complaints of knee pain. The Court has held, however, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. At worst, the Veteran has flexion limited to 90 degrees. Even when considering pain and functional loss, his limitation of flexion does not more closely approximate 45 degrees. Therefore, the criteria for a 20 percent evaluation under Diagnostic Code 5260 are not met. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of extension of the leg, a 10 percent evaluation is warranted when extension of the leg is limited to 10 degrees. A 20 percent evaluation is warranted when extension is limited to 15 degrees. 38 C.F.R. § 4.71a. Normal extension is 0 degrees. 38 C.F.R. § 4.71a, Plate II. At his October 2008 VA examination, his extension was normal at 0 degrees with no pain. He had no additional limitation of motion due to functional loss after repetitive motion. At his May 2013 VA examination his extension was again normal at 0 degrees with no objective evidence of painful motion. He denied flare ups. He had no additional limitation of motion due to functional loss after repetitive motion. VA treatment records show subjective complaints of knee pain. However, the pain alone does not rise to the level of functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran's extension is consistently normal without objective evidence of painful motion. His limitation of extension does not more closely approximate the criteria for a 20 percent evaluation under Diagnostic Code 5261, which requires that his extension be limited to 15 degrees. Therefore, the criteria for a 20 percent evaluation under Diagnostic Code 5261 are not met. 38 C.F.R. § 4.71a. Separate ratings are also available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As discussed above, the Veteran's extension is normal. Therefore, his knee extension is not limited to 5 degrees, which is required for a noncompensable evaluation under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Because his extension is normal, separate evaluations under Diagnostic Codes 5260 and 5261 are not warranted. VAOPGCPREC 9-98 (1998); VAOPGCPREC 9-2004 (2004). The Veteran has been diagnosed with degenerative joint disease (DJD) of the right knee. Under Diagnostic Code 5003, degenerative arthritis, if the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In this case, the Veteran's 10 percent rating under Diagnostic Code 5260 is based upon painful motion. As noted above, his flexion is at worst 90 degrees, which does not meet the criteria for a noncompensable evaluation under Diagnostic Code 5260, which requires that flexion be limited to 60 degrees. 38 C.F.R. § 4.71a. Therefore, this portion of Diagnostic Code 5003 is not applicable to the Veteran because it would constitute impermissible pyramiding. 38 C.F.R. § 4.14. In the absence of limitation of motion, a 10 percent evaluation is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. § 4.71a. There is x-ray evidence that the Veteran has DJD of the right knee. A 20 percent rating is warranted under DC 5003 where there is x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. For the purposes of rating disabilities from arthritis, the following are considered major joints: shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45(f). The Veteran does not have arthritis of two major joints or two or more minor joints. Further, he has never had an incapacitating exacerbation. Therefore his disability picture does not more closely approximate a 20 percent evaluation under Diagnostic Code 5003. A separate rating may also be assigned for instability or recurrent subluxation. Under Diagnostic Code 5257 other impairment of the knee, a 10 percent evaluation is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent evaluation is warranted when there is moderate recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Diagnostic Code 5257 is based upon instability and subluxation, not limitation of motion, as a result, the criteria set forth in DeLuca do not apply. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). 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 The evidence of record does not show that the Veteran has instability or subluxation of the knee, nor has he so claimed. At his October 2008 VA examination, clinical tests showed his knee joint to be stable. At his May 2013 VA examination, his anterior, posterior, medial, and lateral instability tests were all normal and the examiner noted that there was no evidence of subluxation or dislocation. The remaining medical evidence does not address whether the Veteran's right knee is stable. Therefore, Diagnostic Code 5257 is not more favorable to the Veteran. A veteran who has arthritis as shown by x-ray and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). For the reasons discussed above, the Veteran's disability picture does not warrant an evaluation under either Diagnostic Code. Lastly, the Veteran's knee has never been ankylosed, there was no malunion or nonunion of the tibia and fibula, and there was no dislocation of the semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5262 (2012); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Although the Veteran had a meniscectomy, the maximum schedular evaluation available under 5259 is 10 percent, and would require symptoms other than those contemplated by the current rating (pain and limitation of motion) in order to warrant a separate rating, which is not shown in the record. Id., Diagnostic Code 5259. Lastly, he does not have genu recurvatum. Id., Diagnostic Code 5263. Accordingly, application of these Diagnostic Codes is unwarranted. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of Diagnostic Code should be upheld if supported by explanation and evidence). In summary, the Veteran's disability picture for his right knee disability does not more closely approximate a 20 percent evaluation under any of the potentially applicable Diagnostic Codes for rating knee disabilities. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 10 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. B. GERD The Veteran's GERD is currently evaluated as noncompensable under Diagnostic Code 7346, hernia hiatal. 38 C.F.R. § 4.114 (2012). Under Diagnostic Code 7346, a 10 percent evaluation is warranted when there are two or more of the symptoms required for a 30 percent evaluation, but with less severity. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114 (2012). At his October 2008 VA examination, he complained of epigastric pain after eating meals. He reported pyrosis with pain radiating into his right shoulder. He also has nausea and "rare" episodes of vomiting. He denied having weight loss, hematemesis, melena, hematochezia, and dysphagia. The examiner concluded that his daily activities and occupation were not impacted by GERD. VA treatment records show that the Veteran takes omeprazole daily to control his GERD. In December 2009 he complained of abdominal pain at night. At his May 2013 VA examination, the Veteran reported having reflux that was worse with spicy food. He did not have dysphagia, pyrosis, regurgitation, substernal arm pain, shoulder pain, sleep disturbance, anemia, weight loss, nausea, vomiting, hematemesis, and melena. The examiner found that he did not have an esophageal stricture. The examiner concluded that the Veteran's GERD did not impact his ability to work. The remainder of the evidence of record does not address the Veteran's symptoms from GERD. The October 2008 VA examination report shows that the Veteran has reported epigastric distress with pyrosis, accompanied by shoulder pain after eating. The evidence does not show that he also has dysphagia and regurgitation. Although he reported "rare" instances of vomiting, this symptom is not persistently recurring, such as the epigastric distress due to pyrosis following each meal. The Board finds, however, that the present case presents sufficient evidence of the presence of some limited recurrent epigastric distress with pyrosis accompanied by shoulder pain to warrant a 10 percent evaluation for the entire initial rating period. See 38 C.F.R. § 4.14 (2012). However, for this period the evidence preponderates against the presence of symptoms such as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, and accompanying substernal or arm or shoulder pain productive of considerable impairment of health, so as to warrant the next higher, 30 percent evaluation. Reviewing the evidence, the Board finds that the overall disability picture for the Veteran's GERD more closely approximates a 10 percent rating under the applicable Diagnostic Code for the entire appeal period under consideration. 38 C.F.R. § 4.7. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The claim is therefore, granted. 38 C.F.R. § 4.3. C. Depression The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204. Withdrawal may be made by the veteran or by his authorized representative. 38 C.F.R. § 20.204. In a July 2013 statement, the Veteran's representative stated that the Veteran wished to withdraw his claim for an increased evaluation for depression. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. D. Extraschedular Evaluations The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's right knee disability and GERD are contemplated by the schedular criteria set forth in the Diagnostic Codes discussed above. Further, no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extraschedular consideration is not in order. Total Rating Based Upon Individual Unemployability (TDIU) When entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In this case, the Veteran has not asserted, and the evidence does not show that the Veteran's service-connected disabilities have caused unemployability. At his May 2013 VA examination, the Veteran stated that he last worked as a salesman, but the Puerto Rico branch of the company closed due to poor sales and he therefore lost his job. He did not assert that he was unemployed because of his service- connected disabilities. Because there is no evidence of unemployability, further consideration of entitlement to a TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). III. Reduction in Rating of Forehead Scar A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. See 38 U.S.C.A. § 1155 (West 2002). Prior to reducing a Veteran's disability rating, VA is required to comply with several general VA regulations applicable to all rating- reduction cases, regardless of the rating level or the length of time that the rating has been in effect. See 38 C.F.R. §§ 4.1 , 4.2, 4.10, 4.13 (2012); see also Brown v. Brown , 5 Vet. App. 413, 420 (1993). These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of the Veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 350 (2000). VA is not limited, however, to medical indicators of improvement. Rather, VA may rely on non-medical indicators of improvement to show that a Veteran is capable of more than marginal employment. Id. It is essential both in the examination and in the evaluation of the disability, that each disability be viewed in relation to its history. 38 C.F.R. § 4.1. When any change in evaluation is to be made, the rating agency should assure itself that there has been an actual change in the conditions, for better or worse, and not merely a difference in thoroughness of the examinations or in use of descriptive terms. 38 C.F.R. § 4.13. Finally, it must be considered that the basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. As to the propriety of the reduction, for reductions in rating to be properly accomplished, specific requirements must be met. See 38 C.F.R. § 3.344; see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). Where a Veteran's schedular rating has been both stable and continuous for five years or more, the rating may be reduced only if the examination on which the reduction is based is at least as full and complete as that used to establish the higher evaluation. 38 C.F.R. § 3.344(a). In this case, consideration of 38 C.F.R. § 3.344 is not warranted because the rating was not in effect for five years or more. The Board is required to establish, by a preponderance of the evidence, that a rating reduction on appeal is warranted. See Kitchens v. Brown, 7 Vet. App. 320, 325 (1995). During the pendency of the Veteran's appeal VA amended a portion of the rating criteria for skin disabilities effective October 23, 2008. However the amendments only apply to applications for benefits received on or after October 23, 2008 or where the Veteran specifically requests review under those regulations. 73 Fed. Reg. 54,708 (Sept. 23, 2008). While the Veteran can request a review under the new criteria, he has not requested such a review. The Veteran's claim for an increased evaluation for a skin condition was received in May 2008. As the Veteran has not requested such review and his claim was received prior to October 23, 2008, it is not necessary for the Board to consider the criteria in effect after October 23, 2008 in adjudicating his claim. Service connection was initially granted for the Veteran's forehead scar in a November 2006 rating decision. This was based upon a September 2006 VA examination report which noted that his scar was 1 centimeter (cm) wide at its widest part. The RO assigned a 10 percent evaluation under Diagnostic Code 7800 because the scar caused one characteristic of disfigurement. 38 C.F.R. § 4.118 (2007). In a March 2009 rating decision, the RO reduced the disability evaluation to a noncompensable rating because an October 2008 examination report noted that it was 2.5 cm long and flat, freely mobile, and nontender. There was no skin breakdown or ulceration and the examiner found that the scar did not cause functional limitation. Further, it did not cause distortion or asymmetry of the face. Based on the VA examiner's findings, the RO concluded that the Veteran's scar did not cause one characteristic of disfigurement and reduced his rating. Diagnostic Code 7800 for the evaluation of disfigurement of the head, face or neck provides that a 10 percent disability rating is assigned when there is one characteristic of disfigurement. 38 C.F.R. § 4.118 (2007). Under Note (1), the eight characteristics of disfigurement are: a scar 5 or more inches (13 or more cm.) in length; a scar at least 1/4 inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; a scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39-sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 square inches (39-sq. cm.); and skin indurated and inflexible in an area exceeding 6 square inches (39- sq. cm.). Id. Based upon the findings of the VA examiner, none of these characteristics are present and a 10 percent evaluation under Diagnostic Code 7800 is not warranted. However, a potentially applicable Diagnostic Code is more favorable to the Veteran. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of Diagnostic Code should be upheld if supported by explanation and evidence). In his April 2009 Notice of Disagreement to the March 2009 rating decision, he asserted that the examiner did not touch his scar and only asked questions. The Veteran asserted that his scar has always been tender and painful when touched. The Veteran is competent to report observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994), Further, there is nothing in the record upon which to base a finding that his statement is not credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In considering the propriety of a reduction, the Board must focus on the evidence of record available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition had demonstrated sustained, actual improvement. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). The Veteran's competent, credible post-reduction statement provides probative evidence that that the time of his October 2008 VA examination, his forehead scar met the criteria for a 10 percent evaluation under Diagnostic Code 7804, which provided a 10 percent rating for superficial scars that are painful on examination. 38 C.F.R. § 4.118. Further, it shows that his disability from his scar had not demonstrated sustained, actual improvement. Affording the Veteran the benefit of the doubt, the preponderance of the evidence is in favor of his claim, the rating reduction was not proper, and the 10 percent evaluation is restored, albeit under Diagnostic Code 7804. See Kitchens v. Brown, 7 Vet. App. 320, 325 (1995). (Continued on the next page) ORDER Service connection for pharyngitis is denied. Service connection for sinusitis is denied. Service connection for a duodenal ulcer is denied. A disability evaluation in excess of 10 percent for a right knee disability is denied. A 10 percent disability rating for GERD is granted, subject to the laws and regulations governing the payment of monetary benefits. The issue of entitlement to a disability evaluation in excess of 30 percent for depression prior to May 29, 2013 and to a disability evaluation in excess of 70 percent thereafter is dismissed. Reduction of the disability rating for a forehead scar from 10 percent to noncompensable, effective October 29, 2008, was not proper; therefore, restoration of a 10 percent rating is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND In May 2013, the Board remanded the Veteran's case so that he could undergo VA examinations for his eczema of the lower extremities and bilateral Achilles tendonitis. The examiner was directed to provide a complete explanation for any opinion(s) rendered. The May 2013 VA examiner concluded that these disabilities were not service connected because there was no evidence of chronic eczema or Achilles tendonitis in his STRs. The examiner did not provide any other statements in support for his negative etiology opinions. Therefore, the rationales are not complete or adequate and a supplemental opinion is needed. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Accordingly, the case is REMANDED for the following action: 1. Return the Veteran's claims file to the examiner who conducted the May 2013 examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. A new examination is only required if deemed necessary by the examiner. The purpose of the examination is to determine whether the Veteran has eczema of the lower extremities and/or bilateral Achilles tendonitis that had its onset or was aggravated during active service, or is otherwise related to any incident of service. The following considerations will govern the opinion: a) The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. b) If a new examination is warranted, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. c) The examiner must provide an opinion as to whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran's eczema of the lower extremities and/or bilateral Achilles tendonitis began during active service or is related to any incident of service. d) The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. It is not sufficient to rely on a lack of evidence in the STRs as the sole reason for providing a negative opinion. e) If the examiner is unable to render the requested opinion(s) without resorting to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the examiner to use his or her medical expertise and training to render an opinion. 2. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). This claim 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. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs