Citation Nr: 1629308 Decision Date: 07/22/16 Archive Date: 08/01/16 DOCKET NO. 13-28 286A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection for a neck disability. 6. Entitlement to service connection for spastic paresis. 7. Entitlement to service connection for a left shoulder disability. 8. Entitlement to a disability rating in excess of 10 percent for scars, residuals, shell fragment wounds, face. 9. Entitlement to a compensable disability rating for scars, shell fragment wounds, left arm. 10. Entitlement to a compensable disability rating for acne with history of pseudofolliculitis barbae. 11. Entitlement to a compensable disability rating for hemorrhoids. 12. Entitlement to a compensable disability rating for dermatophytosis. 13. Entitlement to an initial compensable disability rating for bilateral hearing loss. 14. Entitlement to a compensable disability rating in for hypertension. 15. Entitlement to a rating in excess of 10 percent for compensable disability rating in excess for degenerative joint disease, lumbar sacral strain. 16. Entitlement to an initial rating in excess of 10 percent for radiculopathy of right lower extremity, associated with degenerative joint disease, lumbar sacral strain. 17. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 18. Entitlement to a total disability evaluation for compensation purposes based on individual unemployability due to service-connected disability (TDIU). 19. Entitlement to a temporary total rating under 38 C.F.R. § 4.29 for PTSD. REPRESENTATION Appellant represented by: Colin E. Kemmerly, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Williams, Counsel INTRODUCTION The Veteran served on active duty from March 1963 to April 1967 and from July 1967 to April 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions in March 2012 and April 2013 of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran testified before the undersigned Veterans Law Judge at a December 2015 videoconference hearing, and a transcript of this hearing is of record. After the hearing, the Veteran's attorney submitted additional evidence and waived his right to have it initially considered by the Agency of Original Jurisdiction (AOJ). 38 C.F.R. §§ 20.800, 20.1304(c) (2015). Regardless, because the case was certified to the Board in May 2015, the Board may consider these records prior to AOJ review. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165. After the case was certified to the Board, the AOJ added additional VA treatment records and examination reports to the claims file, some of which were not reviewed by the AOJ. Regarding the claims decided herein, as the information contained in the newly obtained ongoing VA records is duplicative of, or of such a similar nature to, information contained VA records associated with the claims file prior to issuance of the August 2013 and February 2015 supplemental statements of the case, the Board finds that a waiver is not necessary as the evidence does not have a separate bearing on the appellate issues decided herein. See 38 C.F.R. § 20.1304(c). This appeal was processed using the Virtual VA and VBMS paperless claims processing systems. Accordingly, any future consideration of the appellant's case should take into consideration the existence of these electronic records. The issues of entitlement to service connection of a left shoulder disability, left ankle disability, neck disability, and spastic paraparesis; increased rating for degenerative joint disease, lumbosacral strain, radiculopathy of right lower extremity, PTSD, hypertension, and hemorrhoids; TDIU; and a temporary total rating under 38 C.F.R. § 4.29 for PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In December 2015, prior to the promulgation of a decision on the issue of entitlement to service connection for a right knee disability, the Veteran withdrew his appeal. 2. In December 2015, prior to the promulgation of a decision on the issue of entitlement to service connection for a left knee disability, the Veteran withdrew his appeal. 3. In December 2015, prior to the promulgation of a decision on the issue of whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta, the Veteran withdrew his appeal. 4. In December 2015, prior to the promulgation of a decision on the issue of entitlement to an initial disability rating in excess of 10 percent for scars, residuals, shell fragment wounds, face, the Veteran withdrew his appeal. 5. In December 2015, prior to the promulgation of a decision on the issue of entitlement to a compensable disability rating for scar, shell fragment wounds, left arm, the Veteran withdrew his appeal. 6. In December 2015, prior to the promulgation of a decision on the issue of entitlement to a compensable disability rating for acne with history of pseudofolliculitis barbae, the Veteran withdrew his appeal. 7. Throughout the period on appeal, the Veteran's hearing loss has been manifested by no more than level I hearing impairment in the left ear and no more than level I hearing impairment in the right ear. 8. Dermatophytosis is manifested by big toenail discoloration on both feet and does not cover an area of at least 5 percent, but less than 20 percent of the entire body, and does not require intermittent systemic therapy. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the Veteran's appealed claim for service connection for a right knee disability have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 2. The criteria for withdrawal of the Veteran's appealed claim for service connection for a left knee have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 3. The criteria for withdrawal of the Veteran's appealed claim for whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 4. The criteria for withdrawal of the Veteran's appealed claim for an increased rating for scars, residuals, shell fragment wounds, face, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 5. The criteria for withdrawal of the Veteran's appealed claim for an increased rating for scar, shell fragment wounds, left arm, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 6. The criteria for withdrawal of the Veteran's appealed claim for a compensable rating for acne with history of pseudofolliculitis barbae have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 7. The criteria for an initial compensable disability rating have not been met for bilateral hearing loss. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2015). 8. The criteria for the assignment of a compensable rating for dermatophytosis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7806, Diagnostic Codes 7800-7805, 7806, 7813 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The RO afforded the Veteran with requisite notice by way of April 2011, October 2012, and December 2012 letters mailed to him prior to the initial adjudication of the claims in March 2012 and April 2013. With regard to the appeal of the initial rating assigned to bilateral hearing loss, the March 2012 rating decision granted the Veteran's service connection claim, and that claim is now substantiated. Moreover, the August 2013 statement of the case set forth the relevant diagnostic codes for rating the disability at issue and included a description of the rating criteria for the current evaluation and for all higher evaluations. As the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required as the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to the duty to assist, the claims file contains the Veteran's service treatment records (STRs), VA medical records, private medical records, Social Security Administration (SSA) records, Board hearing transcript, and the statements of the Veteran. At his Board hearing in December 2015, the Veteran declined to provide testimony on both his bilateral hearing loss and dermatophytosis although his representative reaffirmed the desire to continue the appeal of these issues. The Veteran was provided with VA examinations for his hearing loss in March 2012 and for his dermatophytosis in September 2012. The Board finds that the examinations are thorough and adequate upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a medical history from the Veteran, and provided the information necessary to evaluate his hearing loss under the applicable rating criteria. Moreover, neither the Veteran nor his representative has objected to the adequacy of the examinations. In Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the United States Court of Appeals for Veterans Claims (Court) held that, relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. At the March 2012 audiological examination, the Veteran denied any impact of his hearing loss on the ordinary conditions of daily life, including the ability to work. As such, the Board finds that the examiner has fully described the functional effect of the Veteran's bilateral hearing loss. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Withdrawal of Appeals 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 2014). 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 (2015). Withdrawal may be made by the Veteran or by his authorized representative. 38 C.F.R. § 20.204 (2015). At his December 2015 hearing before the Board, the Veteran withdrew his appeal as to the issues of entitlement to service connection for a right knee disability and a left knee disability, whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta, and increased ratings for acne with history of pseudofolliculitis barbae and scars, residual, shell fragment wounds of his face and left arm. The Veteran's statement indicating his intention to withdraw the appeal as to these issues, once transcribed as a part of the record of his hearing, satisfies the requirements for the withdrawal of a substantive appeal. See Tomlin v. Brown, 5 Vet. App. 355 (1993). In the present case, the Veteran has withdrawn his appeals as to the issues of entitlement to service connection for a right knee disability and a left knee disability, whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta, and increased ratings for acne with history of pseudofolliculitis barbae and scars, residual, shell fragment wounds of the face and left arm; and hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeals and they are dismissed. Disability Rating Law and Regulations Disability ratings are determined by applying a schedule of ratings that 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 (2015). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis Bilateral hearing loss The Veteran contends that a compensable rating is warranted for his bilateral hearing loss. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by puretone audiometric tests at the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability from bilateral defective hearing, the rating schedule establishes 11 auditory acuity levels designated from level I, for essentially normal acuity, through level XI, for profound deafness. 38 C.F.R. § 4.85 (2015). When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a) (2015). Similarly, if the puretone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). Table VIA, "Numeric Designation of Hearing Impairment Based Only on Pure Tone Threshold Average," is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on the puretone threshold average. Table VIA will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of Section 4.86, described in the preceding paragraph. 38 C.F.R. § 4.85(c). The evidence during the applicable period includes a March 2012 VA examination report where the Veteran was seen by a VA audiologist and evaluated for hearing loss. On the authorized audiological evaluation in March 2012, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 10 25 40 LEFT 5 10 20 35 70 The average puretone threshold for the right ear was 21.25 decibels. The average puretone threshold for the left ear was 33.75 decibels. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 96 in the left ear. The Veteran indicated that his hearing loss did not impact ordinary conditions of daily life, including ability to work. Based on the audiometric findings noted above, Table VI indicates a numeric designation of no worse than level I hearing in each ear. The point of intersection on Table VII reflects that the level of hearing loss is consistent with a noncompensable evaluation. Thus the Veteran does not meet the criteria for a compensable rating for his hearing impairment. The Board notes that Table VIA does not provide entitlement to a higher rating based on the above audiological examination because the puretone thresholds were not 55 decibels at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz), nor was the puretone threshold at 30 decibels or lower at 1000 Hz and 70 decibels or more at 2000 Hz for either ear. 38 C.F.R. § 4.86. Thus, combining the numerical designations under Table VII results in a noncompensable disability rating. 38 C.F.R. § 4.85, Diagnostic Code 6100. As noted above, the Veteran declined to give testimony regarding his hearing loss during his December 2015 Board hearing. VA and private treatment records are negative for any complaints or treatment regarding hearing loss. As described, the February 2012 audiological results do not show that a compensable schedular rating is warranted for the Veteran's bilateral hearing loss. The March 2012 VA examination report represents the best evidence for deciding the claim for as it contains comprehensive audiometric testing sufficient for rating the disability. Based on the foregoing, the Board concludes that the Veteran's bilateral hearing loss is not manifested by symptomatology that more nearly approximates the criteria for a compensable rating for the disorder. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Dermatophytosis The Veteran contends that a compensable rating is warranted for his dermatophytosis. The Veteran's dermatophytosis is rated under Diagnostic Code 7813 at a noncompensable level (zero percent rating). 38 C.F.R. § 4.118, Diagnostic Code 7813. Specifically, 38 C.F.R. § 4.118, Diagnostic Code 7813 states that dermatophytosis is to be rated as disfigurement of the head, face, or neck (under Code 7800); scars (under Codes 7801, 7802, 7803, 7804, or 7805); or dermatitis (under Code 7806) depending upon the predominant disability. Here, the clinical record reflects that the Veteran's dermatophytosis is most appropriately evaluated as dermatitis under Diagnostic Code 7806 as there is no evidence or allegation that the disability involves any area on the body other than the feet, or that there are resulting scars. Under 38 C.F.R. § 4.118, Diagnostic Code 7806, a noncompensable rating is warranted when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected; and no more than topical therapy is required during the past 12-month period. A 10 percent rating is warranted when there is at least 5 percent, but less than 20 percent of the entire body is covered; or at least 5 percent, but less than 20 percent of exposed areas are affected; or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. The Veteran was afforded a VA examination in September 2012 in which he reported having dermatophytosis diagnosed in 1974. It was noted that the Veteran had not been treated with oral or topical medications in the past 12 months for any skin condition. Upon examination, it was stated that the Veteran had infections of the skin on less than five percent of the total body area and exposed body area. Specifically, the examiner reported that the Veteran's big toenail were discolored and thick on both feet. No other pertinent physical findings, complications, conditions, signs and/or symptoms were noted. VA and private treatment records have been negative for any additional symptoms or treatment regarding the Veteran's dermatophytosis. On review of the foregoing evidence, the Board finds that the preponderance of the evidence is against a finding that the Veteran's dermatophytosis is productive of criteria warranting a compensable rating. In this regard, while the Veteran has demonstrate symptoms such as thick and discolored toenails, he has not reported and the evidence does not show that there is involvement of at least five percent of the entire body or exposed areas are affected. Furthermore, the Veteran's treatment has not included intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs, and the clinical records on file do not reflect that intermittent systemic therapy is required. The Veteran has not reported, and the record does not reflect, the use of antifungal medication, oral and topical. Based on the foregoing, the Board concludes that the disability due to the Veteran's dermatophytosis is not manifested by symptomatology that more nearly approximates the criteria for a compensable rating for the disorder. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's hearing loss and dermatophytosis are specifically contemplated by the schedular rating criteria. The Veteran's hearing loss has been manifested by diminished hearing. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Decreased hearing is contemplated by the hearing impairment levels. 38 C.F.R. §§ 4.85, Diagnostic Code 6100. Similarly, the Veteran's dermatophytosis causes discolored and thick toenails; and the rating criteria contemplates such impairment. As discussed above, there are higher ratings available under the applicable diagnostic codes, but the Veteran's disabilities are not productive of the manifestations that would warrant the higher ratings. Thus, the Board finds the criteria for the evaluations assigned more than reasonably describes the Veteran's disability level and symptomatology, and therefore, the schedular evaluations are adequate, and consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" and/or referral is not required. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER The appeal concerning the issue of entitlement to service connection for a right knee disability is dismissed. The appeal concerning the issue of entitlement to service connection for a left knee disability is dismissed. The appeal concerning the issue of whether new and material evidence has been submitted to reopen a claim for service connection for spina bifida occulta is dismissed. The appeal concerning the issue of entitlement to a disability rating in excess of 10 percent for scars, residuals, shell fragment wounds, face is dismissed. The appeal concerning the issue of entitlement to a compensable disability rating for scars, shell fragment wounds, left arm is dismissed. The appeal concerning the issue of entitlement to a compensable disability rating in excess for acne with history of pseudofolliculitis barbae is dismissed. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to a compensable rating for dermatophytosis is denied REMAND Remand is necessary in this case for the following reasons. Service connection Left shoulder, neck, and spastic paresis The Veteran has consistently alleged that he has a left shoulder and neck disability, as well as spastic paraparesis which he contends are related to service. VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). With regard to the Veteran's left shoulder disability, the Veteran has asserted that he injured his left shoulder in service and that he is unable to lift it. See December 2015 Hearing Tr. at 15-16. He also asserted that his left shoulder disability gradually progressed since service and now he has no strength in it. Although service treatment records a negative for any left shoulder injury or diagnoses, the Veteran is competent to report that he injured his left shoulder in service. According to private treatment records dated in February 2011, the Veteran's MRI of the shoulder reflects impingement and acromioclavicular arthritis. Additional diagnoses regarding the left shoulder given by the same physician in March 2011 included biceps tendonitis, SLAP tear, and possible rotator cuff tear. Given the Veteran's complaint of left shoulder injury in service and his current left shoulder diagnoses noted, a VA examination is warranted. McLendon, 20 Vet. App. at 86. With regard to the Veteran's claimed neck disability, according to the April 2013 rating decision, the RO noted that evidence does not show an event, disease or injury in service. However, a February 1976 service treatment record reflects that the Veteran complained of pain in the right side of neck and when moving in any direction at that time. Recent private treatment records show diagnoses including severe cervical degenerative disc disease. See February 2011 private treatment record. In light of the Veteran's contentions, recorded complaints of neck pain in service and the noted current neck disability, a VA examination is warranted. McLendon, 20 Vet. App. at 86. With regard to spastic paresis, VA treatment records reflect that he has spastic paraparesis associated with his cervical spine condition. See June 2013 and June 2014 VA treatment records. As the matter of entitlement to service connection for an a neck disability will have a substantial effect on the merits of his claim for spastic paraparesis, it is inextricably intertwined and remanded with the Veteran's claim for service connection for a neck disability and must be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). Left ankle Once VA has provided a VA examination, even if it was not statutorily obligated to do so, an adequate one must be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran currently has degenerative arthritis in the left ankle. A January 1971 service treatment record shows that the Veteran complained of aching pain in left ankle and noted history of chipped bone in left ankle. A May 1974 service treatment record reflects a finding of fracture of left tarsal navicular. The Veteran was afforded a VA examination to determine the nature and etiology of his claimed left ankle disability in May 2012. While the May 2012 VA examiner discussed the January 1971 and July 1975 ankle injuries which he described as twisting injuries resulting in ligament sprain, he did not discuss the May 1974 fracture noted in service. The examiner's negative opinion is based, in part, on an inaccurate factual basis, rendering the opinion inadequate. See Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993). Given the Veteran's current diagnoses and the lack of a medical opinion of record which speaks to the nature and etiology of the Veteran's these diagnoses in light of the service treatment records, the Veteran is entitled to an addendum opinion, and a VA examination if necessary, to clarify whether any current diagnosed left ankle condition is related to his military service. Accordingly, remand is warranted to obtain an addendum opinion addressing the Veteran's claimed left ankle disability. Increased rating claims When the evidence suggests that a disability has worsened since the veteran's last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159(c)(4). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Hypertension and hemorrhoids During the December 2015 Board hearing, the Veteran reported that his hypertension and hemorrhoids had worsened. The record shows that the Veteran subsequently underwent additional VA examinations of his hypertension and hemorrhoids in December 2015. This evidence has not been considered by the AOJ. As the Veteran's representative only waived consideration of specific pieces of evidence by the AOJ, which did not include the recent VA records and December 2015 VA examination results, the AOJ must issue an Supplemental Statement of the Case (SSOC) with regard to the Veteran's claims for an increased rating for hypertension and hemorrhoids. As such, the Veteran's claims must be remanded for AOJ consideration of the evidence added to the record since the August 2013 and February 2015 SSOCs. PTSD; degenerative joint disease, lumbosacral strain; and radiculopathy of right lower extremity With regard to the Veteran's service-connected degenerative joint disease, lumbosacral strain, radiculopathy of right lower extremity, and PTSD, he testified that they had worsened since his last examination. Specifically, he stated that he was having more problems with his PTSD. See December 2015 Hearing Tr. at 12. Regarding his back disability and associated radiculopathy, the Veteran reported that it is hard for him to stand and brush his teeth and that the pressure from his back affects his legs and the way he walks. See December 2015 Hearing Tr. at 5. Given the evidence of increased symptomatology, new VA examinations are warranted to determine the current severity of the Veteran's service-connected PTSD; degenerative joint disease, lumbosacral strain; and radiculopathy of right lower extremity. TDIU and Temporary Total Rating under 38 C.F.R. §§ 4.29 The Veteran's claims for TDIU and a temporary total rating under Paragraph 29 are inextricably intertwined with the increased rating and service connection claims being remanded. The outcome of the appeal on these issues has an immediate effect on his claims for TDIU and a temporary total rating. Consideration of the claims for TDIU and temporary total ratings must be deferred pending resolution of those increase rating and service connection claims. See Harris, 1 Vet. App. at 183; see also Tyrues, 23 Vet. App. at 178. VA treatment records The most recent VA treatment records associated with the claims file are dated in March 2016 from Biloxi VA Medical Center (VAMC). During the 2016 Board hearing, the Veteran stated that he received treatment from VAMCs in Biloxi and Houston and attended group meetings for his PSTD. Updated VA records dated from March 2016 to the present must be obtained and associated with the record. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the record all of the Veteran's pertinent VA treatment records, dated from March 2016 to the present, to include from VAMCs in Biloxi and Houston. 2. Then schedule the Veteran for an appropriate VA examination in order to determine the nature and etiology of his claimed neck disability and spastic paraparesis. The examiner should review the entire record, including this REMAND. All necessary studies and tests should be conducted. Following an examination of the Veteran and a review of the Veteran's service treatment records, lay statements, and post-service treatment records, the examiner is asked to answer the following: Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed neck disability and/or spastic paraparesis was incurred during or is otherwise related to the Veteran's period of active service? Is it at least as likely as not (i.e., 50 percent or greater probability) that any diagnosed arthritis involving the neck manifested within one year of the Veteran's period of active service? The examiner should specifically address the Veteran's in-service complaints, diagnoses, and treatment regarding his neck. The examiner must provide reasons for all opinions, addressing the relevant medical and lay evidence. 3. Schedule the Veteran for an appropriate VA examination in order to determine the nature and etiology of his claimed left shoulder disability. The examiner should review the entire record, including this REMAND. All necessary studies and tests should be conducted. Following an examination of the Veteran and a review of the Veteran's service treatment records, lay statements, and post-service treatment records, the examiner is asked to answer the following: Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed left shoulder disability was incurred during or is otherwise related to the Veteran's period of active service? Is it at least as likely as not (i.e., 50 percent or greater probability) that any diagnosed arthritis of the left shoulder manifested within one year of the Veteran's period of active service? The examiner must provide reasons for all opinions, addressing the relevant medical and lay evidence. 4. Then refer the entire record to the VA examiner who conducted the May 2012 VA examination regarding the Veteran's claimed left ankle disability. If deemed necessary, another examination should be conducted. The examiner should review the entire record, including this REMAND. Following a review of the Veteran's service treatment records, lay statements, and post-service treatment records, and completion of the examination, if necessary, the examiner is asked to answer the following: Is it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed left ankle disability was incurred during or is otherwise related to the Veteran's period of active service? Is it at least as likely as not (i.e., 50 percent or greater probability) that any diagnosed arthritis of the left ankle manifested within one year of the Veteran's period of active service? The examiner should specifically address the Veteran's in-service complaints, diagnoses, and treatment regarding his left ankle, to include the May 1974 service treatment record finding of fracture of left tarsal navicular. The examiner must provide reasons for all opinions, addressing the relevant medical and lay evidence. 5. Then, schedule the Veteran for a new VA examination to assess the severity of his PTSD. The examiner should review the entire record, including this REMAND. All necessary studies and tests should be conducted and all clinical findings must be reported in detail. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the General Rating Formula for Mental Disorders. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran's PTSD. 6. Schedule the Veteran for a new VA spine examination. The examiner should review the entire record, including this REMAND. All necessary studies and tests should be conducted. The examiner should: a. Report the Veteran's ranges of thoracolumbar spine motion in degrees. b. Determine the extent the thoracolumbar spine disability is manifested by weakened movement, stiffness, excess fatigability, incoordination, flare-ups, or pain. This determination should be made in terms of the degree of additional range-of-motion loss. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the thoracolumbar spine is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. c. Indicate whether the Veteran has intervertebral disc syndrome (IVDS) related to his service-connected back disability and whether he experiences incapacitating episodes (physician-prescribed bed rest) and the frequency and total duration of such episodes over the course of a year. d. The examiner should also identify any neurological impairment(s) associated with the Veteran's service-connected back disability, in addition to his service connected radiculopathy of the right lower extremity, including any impairment manifested by pain and numbness and describe any symptoms and functional limitations associated with such impairment(s). e. Finally, the examiner should describe any occupational impairment(s) associated with the Veteran's back disability. The examiner must provide reasons for all opinions. 7. Schedule the Veteran for a new VA examination to assess the severity of his radiculopathy of the right lower extremity. The examiner should review the entire record, including this REMAND. All necessary studies and tests should be conducted and all clinical findings must be reported in detail. Following an examination of the Veteran and a review of the record, the examiner is asked to answer the following: a. Does the Veteran have complete paralysis of his right lower extremity, such that his foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or lost? b. If not, does the Veteran have incomplete paralysis of his right lower extremity? c. If the Veteran does have incomplete paralysis of his right lower extremity, which rating most accurately reflects his condition: severe with marked muscular atrophy; moderately severe; moderate; or mild? Please provide reasoning for your rating. d. The examiner should also describe any occupational impairment(s) associated with the Veteran's his radiculopathy of the right lower extremity. The examiner must provide reasons for all opinions. 8. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal, including the Veteran's TDIU and temporary total claims, in light of the evidence received since the August 2013 and February 2015 SSOCs, including the December 2015 VA examination reports regarding hypertension and hemorrhoids. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his attorney must be provided with a Supplemental Statement of the Case and be afforded a 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 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 2014). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs