Citation Nr: 1329541 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 10-40 685A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for residuals of traumatic brain injury (TBI). 2. Entitlement to service connection for a left ankle disability. 3. Entitlement to an initial compensable evaluation for tinea versicolor. 4. Entitlement to a compensable initial evaluation for intervertebral disc syndrome (IVD). 5. Entitlement to a compensable initial evaluation for scars on the right elbow, hip and knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from July 1999 to June 2000 and from May 2004 to May 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 decision by the RO which, in part, denied service connection for TBI and a left ankle disability and granted service connection, and assigned noncompensable evaluations for the remaining issues on appeal. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issues of service connection for TBI and increased ratings for tinea versicolor and IVD are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDINGS OF FACT 1. The Veteran is not shown to have a left ankle disability at present which is related to service. 2. The Veteran's nonlinear scars, measuring 2 by 5-cm on the right elbow and right hip and 2 by 3-cm on the right knee, are not tender to palpation, depressed, disfiguring or adherent to the underlying tissue and do not cause any functional impairment. CONCLUSIONS OF LAW 1. The Veteran does not have a left ankle disability due to disease or injury which was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2012). 2. The criteria for a compensable initial evaluation for scars on the right elbow, hip and knee are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.40, 4.118, Diagnostic Code 7804 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claims, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Such notice must indicate that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id; 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The notification obligation in this case was accomplished by way of a letter to the Veteran dated in January 2009. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Furthermore, no argument has been advanced that there exists any error in the accomplishment of the duty to notify. Moreover, based on the communications sent to the Veteran and his representatives over the course of this appeal, he has shown actual knowledge of the evidence that he is required to submit in this case. Based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what is needed to prevail on his claim. As to VA's duty to assist, the Board finds that all necessary development has been accomplished and that appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). All service treatment records (STRs) and VA and private medical records have been obtained and associated with the Veteran's VA electronic medical records. The Veteran was examined by VA during the pendency of this appeal and was afforded an opportunity for a personal hearing, but declined. The Board finds that the pre-discharge VA examination was comprehensive and adequate upon which to base a decision on the merits of the issues addressed in this decision. The examiner personally interviewed and examined the Veteran, elicited a medical history and provided comprehensive and rational explanations for the conclusions reached. Further, neither the Veteran nor his representative have made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues addressed in this decision, and have not argued that any error or deficiency in the accomplishment of the duty to assist has prejudiced him in the adjudication of his appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Accordingly, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (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) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. An alternative method of establishing the second and third Shedden/Caluza elements for a chronic disability listed under 38 C.F.R. § 3.309(a), is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also, Barr v. Nicholson, 21 Vet. App. 303 (2007); Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition listed under 38 C.F.R. § 3.309(a) was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). Where a Veteran served for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year of date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). Medical evidence of a "chronic" disease should set forth the physical findings and symptomatology elicited by examination within the applicable period. 38 C.F.R. § 3.307(b); Oris v. Derwinski, 2 Vet. App. 95, 96 (1992). A chronic disease need not be diagnosed during the presumptive period but characteristic manifestations thereof to the required degree must be shown by acceptable medical and lay evidence followed without unreasonable time lapse by definite diagnosis. 38 C.F.R. § 3.307(c); Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). Left Ankle Disability The Veteran contends that he suffered multiple left ankle sprains during service and believes that his current left ankle problems are due to his ankle injuries and carrying heavy equipment on long marches and other training exercises in service. Regarding his contentions, while the Veteran may believe that his current left ankle disability is related to service, he has not presented any competent medical evidence to support that assertion. Direct service connection requires a finding that there is a current disability that has a relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). The Veteran's STRs showed that he was treated for a left ankle sprain as a cadet at West Point in July 2002. At that time, the Veteran reported that he turned his left ankle during a training exercise, but was able to complete his run. On examination, he had good range of motion and normal strength (5/5) in the ankle. There was grade II edema and some tenderness to palpation. The assessment was grade I/II left ankle sprain, and the Veteran was placed on light duty and given physical therapy for two weeks. The STRs showed no further complaints, treatment, abnormalities or diagnosis for any left ankle problems during the Veteran's remaining two years at West Point, or at anytime during his five years of active military service. The Veteran made no mention of any left ankle problems on a flight examination while at West Point in September 2003, and no pertinent abnormalities were noted on examination. Similarly, the Veteran made no mention of any left ankle problems on a Report of Medical History for separation from service in November 2008, and specifically denied any arthritis, foot trouble, swollen or painful joints, or any impairment of the feet, and denied any need to wear a brace or supportive device. On examination, the Veteran's lower extremities and feet were normal. When examined by VA in February 2009, the Veteran reported that he sprained his left ankle playing sports on numerous occasions growing up and on several occasions in service, but said that his service records only showed treatment for one severe ankle sprain during a training run in July 2002. During the examination, the Veteran reported that he initially sprained his ankle in 1999 while playing unit basketball, and that his ankle was weak after he recovered. He said that he aggravated his ankle during airborne school and on road marches, and that the defining injury occurred during a training run in July 2002. He said that both ankles pop but that his left was worse than the right, and that he wakes up with stiffness in both ankles every morning. He denied any other significant functional or activity limitations due to his left ankle. On examination, there some reduced range of motion, but no tenderness to palpation or any additional limitation of motion on repetitive movement in the left ankle. The diagnosis was subjective complaints of recurring stiffness - no pathology found to render a diagnosis. In a letter dated in April 2010, the Veteran reported that he reinjured his left ankle playing rugby in France in February 2010. He reported that his ankles were weak, historically, and that this sprain was particularly severe and long-lasting, and stuff and noticeably swollen for several weeks. The Veteran submitted copies of private medical records which showed that he was treated for a left ankle sprain in France in February 2010. VA outpatient notes showed that the Veteran was seen for his left ankle in April 2010. The Veteran reported that he injured his ankle playing rugby in February 2010, and that he was treated by a private doctor in France. He said that his ankle had improved since then, but that he had occasional severe pain, particularly when moving it in certain positions. His main concern was whether he could play rugby on the upcoming weekend. On examination, there was some tenderness, minimal swelling and pain on lateral movement, but no other pertinent abnormalities were noted. X-ray studies showed no acute fracture or dislocation, the ankle mortise was intact, the joint spaces were well maintained and the soft tissues were unremarkable. The impression was no acute fracture, dislocation or degenerative changes. When seen by VA in September 2010, the Veteran reported that he had marked pain and swelling for three months after injuring his left ankle in February 2010, and said that it felt better since July 2010. X-ray studies at that time showed very mild degenerative osteoarthritic changes in the intertarsal joint. The ankle mortise was grossly maintained and the rest of the articular surfaces and joint spaces were adequately maintained. There was no acute displaced fracture or dislocation, and no acute bony, soft tissue or joint space abnormalities. The assessment included left ankle pain likely due to overpronation, heel cord tightness and recurrent "ATFL" sprains. Other than the single incident of a relatively mild (Grade I/II) left ankle sprain in July 2002, during the Veteran's cadet training, the STRs, including his separation examination in November 2008, were entirely negative for any complaints, findings or diagnosis for any left ankle problems. The records showed that the Veteran was placed on light duty for two weeks and was referred to physical therapy, but do not show any further ankle problems during his remaining two years at West Point, or at anytime during his four years of active service. While the Veteran had some decreased motion in the left ankle when examined by VA in January 2009, there were no objective findings or diagnostic evidence of any pathology or pertinent abnormalities. The evidence of record showed that the Veteran suffered a severe left ankle sprain playing rugby in February 2010, and that he was seen by VA on several occasions subsequent to that injury. When seen by VA in April 2010, the Veteran had some swelling and pain on lateral movement of his ankle. However, x-ray studies were completely negative, and showed no evidence of arthritis or any degenerative changes. When seen by VA in September 2010, the Veteran reported that he wore a brace on his left ankle for a month after the February 2010 injury, with no improvement, and said that his ankle pain was on and off since July 2010. In deciding a claim for service connection on the merits, the Board must assess the credibility and weight of all evidence, including the Veteran's statements and the medical evidence to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991); Hatlestad v. Derwinski, 1 Vet. App. 164, 169-70 (1991); Gilbert v. Derwinski, 1 Vet. App. 49, 59 (1990). Concerning the Veteran's contentions, while his is competent to provide evidence regarding his observations and experiences, any such assertions must be weighed against other inconsistent or contradictory evidence of record. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Maxon v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom Maxon v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000) [it was proper to consider the Veteran's entire medical history, including a lengthy period of absence of complaints]; see also Forshey v. Principi, 284 F. 3d 1335 (Fed. Cir. 2002) ["negative evidence" could be considered in weighing the evidence]. In this regard, contrary to the Veteran's assertions that he suffered multiple ankle sprains in service, the STRs showed that the only ankle injury he incurred was during his cadet training at West Point in 2002, two years prior to his active duty service. The records showed that his ankle sprain apparently resolved without residual disability as evidence by the fact that he never required or sought medical attention for any left ankle problems during his entire five years of active service. Clearly, the STRs do not reflect a chronic left ankle disability in service. Likewise, the Veteran made no mention of any ankle problems at the time of his separation examination in November 2008, and no pertinent abnormalities were noted at that time. While the Veteran reported a history of chronic ankle problems when examined by VA in January 2009, there was no clinical or diagnostic evidence of any left ankle pathology at that time. As to the Veteran's assertion that he suffered multiple ankle injuries during his military service, the Board finds that his assertions are not supported by any objective evidence. That the Veteran would report a history of a broken wrist in middle school (for which he reported no problems or treatment during service), that he was sea sick once, or that he would "vaguely" recall having bronchitis during high school when examined for service separation in 2008, but that he would not report what he now claims to have been chronic ankle problems during service is not rational or believable. Given the facts in this case, the Board does not find the Veteran's assertions of a chronic left ankle disability in service believable, and declines to assign his contentions any evidentiary weight. In this case, the evidence showed that the Veteran suffered a severe, intercurrent left ankle injury in February 2010 which, according to the Veteran, did not heal completely until July 2010. (See September 2009 VA outpatient note). Significantly, VA x-ray studies of his left ankle in April 2010, were entirely negative and showed no evidence of any degenerative changes in the ankle. The first evidence of arthritic changes in his left ankle was shown on a VA treatment note in September 2010. Inasmuch as there was no objective evidence of any chronic left ankle problems or disability in service, no objective evidence of arthritis within one year of discharge from service, and no competent medical evidence relating any current left ankle disability to service, the record affords no basis to grant service connection. Accordingly, the service connection for a left ankle disability is denied. Increased Ratings - In General When, as here, the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Right Elbow, Hip and Knee Scars Initially, the Board notes that while the remaining increased rating issues on appeal are being remanded for a more current VA examination, the nature of the Veteran's right elbow, hip and knee scars are not subject to material change. That is, the scars are superficial in nature and do not involve nerve damage or tissue loss, such that a more current examination would show an increase in the size or symptoms associated with the scars. The Veteran does not claim, nor does the current evidence of record show any treatment for the scars or any residual disabilities since his initial injury in 2006. Therefore, given the nature of the scars and the clinical findings on the February 2009 VA examination, the Board finds that the evidence of record is adequate to adjudicate this issue, and that there would be no benefit to the Veteran by remanding the matter for a more current examination. The STRs, are completely silent for any complaints, treatment, abnormalities or diagnosis for any scars on the right elbow, hip or knee. On his service separation examination in November 2008, the Veteran was shown to have a scar on the right elbow, that the examiner indicated was of "no issue." When examined by VA in February 2009, the Veteran reported that he fell off a motor bike while on leave in Thailand in December 2006, and suffered "road rash" to his right elbow, hip and knee. He said that he was initially treated at a local clinic, and that he was treated at the battalion aid station when he returned to his unit, but had no medical records for this treatment. On examination, there were three well-healed, superficial, nonlinear scars, one each on the right elbow, right hip, and right knee. The scars on the elbow and hip measured 2 by 5 cm, and 2 by 3-cm on the right knee. The scars were asymptomatic and not tender to palpation, depressed, disfiguring or adherent to the underlying tissue and did not cause any functional impairment. The diagnosis was superficial scars over the right elbow, hip and knee, asymptomatic. In this case, the Veteran was assigned a noncompensable evaluation for scars on the right elbow, hip and knee under Diagnostic Code (DC) 7804, by analogy to scars that are unstable or painful. A 10 percent evaluation is assigned for one or two scars that are unstable or painful, 20 percent for three or four scars, and 30 percent for five or more scars. Other potentially applicable rating codes include DC 7801, 7802 and 7805. DC 7801 governs the evaluation of scars other than on the head, face, or neck, that are deep and nonlinear. A 10 percent disability evaluation is for assignment for an area or areas exceeding 6 square inches. A 20 percent disability evaluation is contemplated for an area or areas exceeding 12 square inches. Under DC 7802, a 10 percent disability evaluation is assigned for scars other than on the head, face, or neck, that are superficial and nonlinear and have an area or areas of 144 square inches or greater. A 10 percent disability evaluation represents the maximum schedular rating available under DC 7802. DC 7805, directs that scars are to be rated on limitation of function of the part affected. 38 C.F.R. § 4.118, DC 7801-7805 (2012). Based on the objective findings from the November 2009 VA examination, the preponderance of the evidence is against the assignment of a compensable evaluation for the Veteran's right elbow, hip and knee scars. The evidence showed that the three scars are well-healed, not deep and do not, individually or in total, encompass an area exceeding six square inches (39 square centimeters) (DCs 7801, 7802). Further, the scars are not shown to be painful or unstable (DC 7804), and do not cause any limitation of motion (DC 7805). Thus, a compensable evaluation is not warranted for the right elbow, hip and knee scars under these or any other potentially applicable diagnostic codes associated with scars and their residual effects. See 38 C.F.R. § 4.118 (2012). Applying the appropriate diagnostic codes to the facts of this case, the objective assessment of the Veteran's present impairment from his right elbow, hip and knee scars does not suggest that he has sufficient symptoms so as to a warrant a compensable evaluation. Accordingly, the noncompensable evaluation assigned accurately depict the severity of the scars for the entirety of the rating period on appeal, and there is no basis for a higher rating. Accordingly, a compensable evaluation for the right elbow, hip and knee scars is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). For the reasons discussed above, the Board finds that the manifestations of the Veteran's right elbow, hip and knee scars are consistent with the schedular criteria, and there is no objective or competent medical evidence that any manifestation related to the service-connected disability is unusual or exceptional. The schedular rating criteria adequately contemplate the degree of impairment caused by the disability, and provides for increased ratings for additional symptoms. In view of this, referral of this case for extraschedular consideration is not in order. Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, the Board finds that a claim for a TDIU was not expressly raised by the Veteran or reasonably raised by the record. The Veteran's right elbow, hip and knee scars do not cause any actual or functional impairment, and are not shown to be of such severity as to preclude substantially gainful employment. Accordingly, the Board finds that consideration of a TDIU is not warranted. The benefit of the doubt has been considered, but there is not an approximate balance of positive and negative evidence regarding the merits of the Veteran's claims. Therefore, that doctrine is not for application in this case because the preponderance of the evidence is against these claims. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Service connection for a left ankle disability is denied. A compensable initial evaluation for right elbow, hip and knee scars is denied. REMAND Although further delay is regrettable, the Board finds that the evidentiary record as currently constituted does not include sufficient information to adequately assess the nature or extent of residual symptoms of the Veteran's documented brain injuries or the current severity of his service-connected tinea versicolor and low back disability. Therefore, additional development of the record is necessary prior to further consideration of the appeal. Concerning the claim of service connection for TBI, the Board notes that the STRs showed that the Veteran was treated on several occasions for blows to the head during boxing matches as a cadet at West Point. The Veteran also reported that he was in close proximity to explosions during his tour of duty in Afghanistan. When examined by VA in February 2009, the examiner indicated that there did not appear to be any noticeable memory problems, but that additional formal memory/psychiatric testing would be necessary to fully evaluate the Veteran's complaints of memory loss. The examiner noted that, at that time, the Veteran was stationed in Italy and that the test would take several hours. Therefore, it would be left up to the Veteran to schedule an appointment at his convenience. In light of the Veteran's contentions, and the documented history of brain trauma in service, the Board finds that a more comprehensive examination is necessary to determine whether he has any residuals of a TBI. Concerning the Veteran's tinea versicolor, the Board notes that the skin disorder is rated under DC 7806, by analogy to dermatitis or eczema, which provides that the disability could also be rated under DCs 7801, 7802, 7804 or 7805, depending upon the predominant disability. Further, DC 7802, Note 2 provides that separate ratings may be assigned for each extremity and for the posterior and anterior trunk, based on the total area of the qualifying scars for each body part affected. Therefore, in order to determine whether separate ratings would be appropriate, the examiner must first indicate whether the predominant disability involves residual scarring or an active skin disease, in this case, tinea versicolor. If the predominant disability is residual scarring, the examiner must then provide an estimate of the affected areas for each body part, i.e., each extremity and the posterior and anterior trunk. As the current evidence of record does not include sufficient information to address these questions, the appeal must be remanded for another VA examination. As to the Veteran's low back disability, given the nature of the disability and the fact that it has been more than four years since he was last examined, the Board finds that a more current examination is warranted. As the Board is precluded from reaching its own unsubstantiated medical conclusions and is instead, bound by the medical evidence of record on these matters, further development is required. See Jones v. Principi, 16 Vet. App. 219, 225 (2002), citing Smith v. Brown, 8 Vet. App. 546, 553 (1996) (en banc); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the case is REMANDED for the following action: 1. The AMC should take appropriate steps to obtain the names and addresses of all healthcare providers who have treated the Veteran for his tinea versicolor, low back disability, and any symptoms associated with TBI since his service separation. Thereafter, the AMC should associate all VA treatment records, not already of record, with Virtual VA records system. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. The Veteran should be afforded a VA examination to determine the nature, extent, and etiology of any traumatic brain injury that he may have. The Veteran's Virtual VA file and a copy of this remand, must be made available to the examiner for review in connection with the examination, and a notation to the effect that this review has taken place should be made in the evaluation report. All indicated should be conducted, and the reports of any such studies should be incorporated into the examination report and associated with his Virtual VA records. The examiner is requested to obtain a detailed history of the Veteran's symptoms as observed by him and others since service, review the record, and offer an opinion as to whether it is at least as likely as not that any diagnosed traumatic brain injury had its clinical onset in service or is otherwise related to service. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. The examiner should review the entire record, including the Veteran's service treatment records prior to formulating an opinion. A fully articulated medical rationale for any opinion expressed must be set forth in the examination report. The examiner should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If the examiner is unable to render an opinion without resorting to speculation, this should be noted and explained. In so doing, the examiner should identify any evidence required in order to render a non-speculative opinion, (which the AMC should attempt to obtain, and then return the claims file to the examiner for completion of the opinion). 3. The Veteran should be afforded VA orthopedic and neurological examinations to determine the current severity of his low back disability. All indicated tests and studies are to be performed. The claims folder must be made available to the examiners for review, and a notation to the effect that this record review took place should be included in the report. The examiners should provide a response to each of the following questions/instructions. The orthopedic examiner should respond to the following: a) Note any limitations of motion in the thoracolumbar spine. b) Indicate whether the thoracolumbar spine exhibits weakened movement, excess fatigability, or incoordination. If feasible, these determinations should be expressed in terms of additional range of motion loss or favorable or unfavorable ankylosis due to any excess fatigability, weakened movement or incoordination. c) Lastly, the examiner should express an opinion on whether pain of the thoracolumbar spine could significantly limit functional ability during flare-ups or when the spine is used repeatedly over a period of time. These determinations should also, if feasible, be portrayed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. The neurological examiner should identify any neurological complaints or findings attributable to the service- connected low back disability. If the Veteran has any associated neurological symptoms, the examiner should provide a written discussion of the degree of any residual weakness or sensory disturbance, and how it impacts on motor function of the lumbar spine. The examiner should also: a) Indicate whether the Veteran has recurring attacks of intervertebral disc syndrome referable to the lumbar spine disability. If so, indicate the degree of intermittent relief he experiences between those attacks. b) The examiner should note whether any intervertebral disc syndrome that may be present in the thoracolumbar spine results in incapacitating episodes, and indicate the total duration of any episodes for each spinal segment. 4. The Veteran should be afforded a VA dermatological examination to determine the current severity of his tinea versicolor. The claims folder should be made available to the examiner for review, and a notation to the effect that this record review took place should be included in the report. All indicated tests and studies are to be performed. The examination report should address the following: a.) Provide a detailed description of the Veteran's tinea versicolor, including any residual scarring, and indicate whether the predominant disability is residual scarring or active skin disease. b.) Indicate whether such symptoms as exudation or itching are constant, whether there are extensive lesions or marked disfigurement, and whether systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12 months; the duration of any systemic therapy should be indicated. c.) Indicate the percentage of the exposed areas affected; the percentage of the entire body affected, and the percentage of each body part affected, i.e., each extremity and posterior and anterior trunk areas (separately). (The description should include both percentage of total body surface in square inches or square centimeters of the skin affected). 5. Following completion of the foregoing, the AMC must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC should determine whether the examiners have responded to all of the questions posed. If not, the reports must be returned for corrective action. 38 C.F.R. § 4.2 (2012). 6. After the requested development has been completed, the AMC should readjudicate the claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. The Veteran 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). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs