Citation Nr: 1647058	
Decision Date: 12/16/16    Archive Date: 12/30/16

DOCKET NO.  13-21 161	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Oakland, California


THE ISSUES

1.  Entitlement to an increased disability rating (or evaluation) in excess of 10 percent disabling for service-connected residual fracture of the right distal radius (a right wrist disability).

2.  Entitlement to an increased (compensable) disability rating (or evaluation) for service-connected residual scars from a laceration of the right pretibial leg (right leg residual scars).

3.  Whether new and material evidence has been received to reopen service connection for posttraumatic stress disorder (PTSD).

4.  Whether new and material evidence has been received to reopen service connection for a left ankle disorder.

5.  Entitlement to service connection for PTSD.

6.  Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include trichotillomania.

7.  Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include Tourette Syndrome.

8.  Entitlement to service connection for a left ankle disorder.

9.  Entitlement to service connection for neurological problems.

10.  Entitlement to service connection for asthma (claimed as a pulmonary condition), to include as due to Agent Orange (herbicide) exposure and smoke inhalation.

11.  Entitlement to service connection for residuals of a left leg fracture (also claimed as a left tibia/fibula fracture).

12.  Entitlement to service connection for a dental disorder for the purpose of obtaining VA compensation (claimed as tooth trauma).

13.  Entitlement to service connection for a noncompensable dental disorder for the purpose of obtaining VA outpatient dental treatment under 38 C.F.R. § 17.161.

14.  Entitlement to service connection for residuals of a broken right arm (other than a right wrist disability).

15.  Entitlement to service connection for a heart condition (claimed as angina pectoris).

16.  Entitlement to service connection for a spinal disorder.

17.  Entitlement to service connection for a burn of the right ankle.

18.  Entitlement to an aid and attendance allowance for the Veteran's spouse.

19.  Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU).

20.  Entitlement to an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability.


REPRESENTATION

Appellant represented by:	Jeany Mark, Attorney


ATTORNEY FOR THE BOARD

L.M. Yasui, Counsel


INTRODUCTION

The Veteran, who is the appellant in this case, served on active duty from June 1971 to December 1973.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2010 and December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California.  This appeal was processed using both the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS).  Accordingly, any future review of this case should take into consideration the existence of this electronic record.

The issues of service connection for an acquired psychiatric disorder other than PTSD, to include Tourette Syndrome, a left ankle disorder, neurological problems, residuals of a left leg fracture, a spinal disorder, and a burn of the right ankle, aid and attendance allowance for the Veteran's spouse, a TDIU, an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability, and a noncompensable dental disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1.  For the entire increased rating period, the right wrist disability has been manifested by symptoms of painful motion that are productive of noncompensable limitation of motion.

2.  For the entire increased rating period, the right wrist disability has not been manifested by ankylosis.

3.  For the entire increased rating period, the residual scars of the right leg have been manifested by tenderness.

4.  An unappealed March 1995 rating decision, in pertinent part, denied service connection for PTSD and a left ankle condition on the basis that there was no confirmed diagnosis of PTSD and there was no chronic condition involving the left ankle.

5.  The Veteran attempted to reopen the claim of service connection for PTSD and the most recent prior final denial is an unappealed January 1997 rating decision.

6.  The Veteran did not appeal the March 1995 and January 1997 rating decisions after being notified of appellate rights, and no additional new and material evidence was received within one year of the decisions.

7.  The evidence received since the March 1995 (final disallowance for service connection for left ankle condition) and January 1997 (final disallowance for service connection for PTSD) rating decisions is neither cumulative nor redundant and addresses the grounds of the prior final denials of service connection for PTSD and a left ankle condition, namely, a current diagnosis, so raises the possibility of substantiating the claims of service connection for PTSD and a left ankle condition.

8.  The Veteran engaged in combat with the enemy during service.

9.  The Veteran has current acquired psychiatric disabilities of PTSD and trichotillomania.

10.  The PTSD and trichotillomania are related to the in-service combat stressor events.

11.  The Veteran had service in the Republic of Vietnam during the Vietnam Era and is presumed to have been exposed to herbicides, including Agent Orange, in service.

12.  The Veteran was exposed to smoke due to brushfire during service.

13.  The Veteran has a current disability of asthma.

14.  The asthma is causally related to in-service exposure to herbicide agents and smoke due to brushfire.

15.  The Veteran did not have, nor has he had at any time proximate to, or during the course of this appeal, a current diagnosis of residuals of a broken right arm other than a right wrist disability or a heart disability.


CONCLUSIONS OF LAW

1.  The criteria for a disability rating in excess of 10 percent for a right wrist disability have not been met or more nearly approximated during any part of the increased rating period.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2015).

2.  Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent rating, but no higher, for two, painful, residual scars of the right leg have been met or more nearly approximated for the entire increased rating period.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7804 (2015).

3.  The March 1995 rating decision to deny service connection for a left ankle condition became final.  38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015).

4.  The January 1997 rating decision to deny reopening of service connection for PTSD became final.  38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015).

5.  New and material evidence has been received to reopen service connection for PTSD and a left ankle disorder.  38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (a) (2015).

6.  Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for PTSD have been met.  38 U.S.C.A. §§ 1110, 1154(b), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015).

7.  Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for an acquired psychiatric disorder other than PTSD, to include trichotillomania, have been met.  38 U.S.C.A. §§ 1110, 1154(b), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015).

8.  Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for asthma as due to herbicide exposure and smoke inhalation have been met.  38 U.S.C.A. §§ 1110, 1112, 1116, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015).

9.  The criteria for service connection for residuals of a broken right arm other than a right wrist disability are not met.  38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015).

10.  The criteria for service connection for a heart disorder are not met.  38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015).



REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015).  Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence.  38 U.S.C.A. § 5103 (a) (West 2014); 38 C.F.R. § 3.159 (b) (2015).  Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim.  38 C.F.R. § 3.159 (b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). 

In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, 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).

In this case, concerning the appeals for increased disability ratings for right leg residual scars and a right wrist disability, the RO provided a timely notice letter to the Veteran in August 2009 and November 2011, respectively.  The letters notified the Veteran of what information and evidence should be submitted to substantiate a claim for an increased rating.  Additionally, the August 2009 and November 2011 letters provided the general criteria for the assignment of an effective date and initial rating. 

Concerning the appeals of service connection for residuals of a broken right arm and a heart disability, in a timely letter dated in November 2011, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain.  The November 2011 letter also included provisions for disability ratings and for the effective date of the claim.

VA also satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.  VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran.  Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private treatment records, VA examination reports, and lay statements.

The Veteran underwent VA examinations in August 2009, December 2013, and March 2016 to assist in determining the current severity of the service-connected right leg residual scars and a right wrist disability.  The Board finds that the VA examination reports are thorough and adequate and provide a sound basis upon which to base a decision with regard to the issues adjudicated below.  The VA examiners personally interviewed and examined the Veteran, including eliciting a history, conducted a physical examination, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes related to the service-connected right leg residual scars and a right wrist disability.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 
22 Vet. App. 295 (2008).  Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issues of an increased rating for right leg residual scars and a right wrist disability has been met.  38 C.F.R. § 3.159 (c)(4).

The Veteran was also afforded an opportunity for a VA medical examination in connection with the claims for service connection for residuals of a broken right arm and a heart disorder in December 2011 and March 2016, respectively.  38 C.F.R. § 3.159(c)(4) (2015).  The Board finds that the December 2011 and March 2016 VA examinations are adequate with regard to the claims for service connection for residuals of a broken right arm and a heart disorder.  The opinions rendered in the December 2011 and March 2016 VA examinations pertaining to the right arm and heart consider all the pertinent evidence of record, to include the statements of the Veteran, and provided rationales for the opinions stated.  Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion as to the issues of service connection for residuals of a broken right arm and a heart disorder has been met.  38 C.F.R. § 3.159(c)(4).

As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case.  The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issues adjudicated herein.  Mayfield, 444 F.3d at 1328.  Hence, no further notice or assistance is required to fulfill VA's duties to notify and assist the Veteran in the development of issues on appeal.

The applications to reopen service connection for PTSD and a left ankle condition, and service connection for PTSD, trichotillomania, and asthma, have been considered with respect to VA's duties to notify and assist.  Given the favorable outcomes adjudicated herein, no conceivable prejudice to the Veteran could result from this decision, and further explanation of how VA has fulfilled the duties to notify and assist is not necessary.  See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

In attempts to reopen previously denied claims for service connection, the duty to assist does not include provision of a medical examination or opinion, unless new and material evidence has been received.  See 38 C.F.R. § 3.159(c)(4)(iii).  The issue of service connection for a left ankle disorder, which is reopened in the decision herein, is Remanded below for further development.

Disability Rating Criteria

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 (2015).  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 (2015).  The Board has a duty to acknowledge and consider all regulations that are potentially applicable.  Schafrath v. Derwinski, 
1 Vet. App. 589 (1991).  Where there is a question as to which of two disability ratings shall be applied, the higher rating 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.  Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran.  38 C.F.R. § 4.3. 

Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  See Francisco v. Brown, 
7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007).  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.  Id.

The Board has reviewed all the evidence in the Veteran's electronic file, with an emphasis on the evidence relevant to this appeal.  Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record.  Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence).  Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims.

Increased Rating for a Right Wrist Disability

The Veteran is in receipt of a 10 percent disability rating for the right wrist disability under 38 C.F.R. § 4.71a, Diagnostic Code 5215, for the entire increased rating appeal period.  The Veteran is right hand dominant.  Under Diagnostic Code 5215 (limitation of motion of the wrist), 10 percent disability ratings are warranted for palmar flexion limited in line with the forearm or dorsiflexion less than 15 degrees.  Diagnostic Code 5215 does not provide for a rating in excess of 10 percent.  38 C.F.R. § 4.71a.

Under 38 C.F.R. § 4.71, Plate I, the standard range of motion for the wrist is extension from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, forearm pronation 0 to 80 degrees, forearm supination 0 to 85 degrees, ulnar deviation from 0 to 45 degrees, and radial deviation from 0 to 20 degrees.

The United States Court of Appeals for Veterans Claims (Court) has emphasized that, when assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements.  See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995).  The rating for an orthopedic disability should reflect functional limitation due to pain which is supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion.  Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled.  A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like.  See 38 C.F.R. § 4.40.  The factors of disability reside in reductions of their normal excursion of movements in different planes.  Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations.  See 38 C.F.R. § 4.45.  It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint.  38 C.F.R. § 4.59.  The application of 38 C.F.R. § 4.59 is not limited to arthritis-related claims.  Burton v. Shinseki, 25 Vet. App. 1 (2011).

Throughout the course of the appeal, the Veteran has contended generally that an increased rating higher than 10 percent is warranted for the right wrist disability.  In the December 2014 Notice of Disagreement, the Veteran, through the representative, indicated that he had flare-ups of the right wrist from repetitive movements and direct pressure.  

During the December 2013 VA examination, upon physical examination, range of motion testing reflected right wrist dorsiflexion to 70 degrees with pain beginning at 35 degrees and palmar flexion to 80 degrees with pain beginning at 50 degrees.  Although the VA examiner noted that the Veteran had functional impairment due to pain on movement, on repetitive motion, there was no additional loss of joint function due to pain, fatigue, weakness, lack of endurance, or incoordination.

The Veteran was afforded another VA examination in March 2016.  At that time, the Veteran reported experiencing pain of the right wrist if he attempts to lift an object or if he turns the right wrist.  Upon physical examination, range of motion testing reflected right wrist dorsiflexion at 15 degrees, palmar flexion at 15 degrees, radial deviation at 15 degrees, and ulnar deviation at 20 degrees.  There was no additional limitation in function of the right wrist following repetitive-use testing with the exception of ulnar deviation, which reflected range of motion at 10 degrees.  

After a review of all the evidence, both lay and medical, for the entire increased rating period, the Board finds that the criteria for an increased disability rating in excess of 10 percent for the right wrist disability have not been met or more nearly approximated.  38 C.F.R. §§ 4.3, 4.7, 4.71a.  A 10 percent rating is the maximum schedular disability rating under Diagnostic Code 5215 for the wrists, both major and minor.  

The Board finds that the weight of the lay and medical evidence demonstrates that the criteria for a disability rating in excess of 10 percent have not been met or more nearly approximated under any other diagnostic codes pertaining to the wrist - specifically, ankylosis under Diagnostic Code 5214.  The range of motion in the right wrist, as documented in the December 2013 and March 2016 VA examination reports, demonstrates that the right wrist disability has not been manifested by ankylosis or limitation of motion that more nearly approximates ankylosis.  Both the December 2013 and March 2016 VA examiners specifically noted that there was no right wrist ankylosis.

The Board has considered whether a higher (increased) disability rating for limitation of motion of the right wrist is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59.  See also DeLuca, 8 Vet. App. at 202.  In this regard, there is no question that the Veteran's right wrist disability has caused pain, which has restricted overall motion.  The Veteran has reported right wrist pain upon motion; however, as noted above, even taking into account additional functional limitation due to pain, VA examination reports and treatment records indicate range of motion for the entire increased rating period that do not more nearly approximate ankylosis of the right wrist.  

A goniometer is defined as "indispensable" by VA regulations.  See 38 C.F.R. 
§ 4.46 ("The use of a goniometer in the measurement of limitation of motion is indispensable in examinations . . .").  Here, while the use of a goniometer was not explicitly noted in the December 2013 or March 2016 VA examinations, the Board finds that the uncertainty as to whether a goniometer was used during the VA examinations does not render the entire VA examinations inadequate, particularly when the range of motion findings are considered with the Veteran's own statements, are within even lay competence to report, and are within medical competence to report to the degree of precision relevant to this case even without the aid of a goniometer, and are considered consistent with other lay and medical evidence of record.  In this case, the Veteran has never been assessed as having ankylosis of the right wrist at any VA examination or during any VA treatment, and the Veteran has not alleged a diagnosis of ankylosis of the right wrist or that the clinical findings that include range of motion testing show or more nearly approximate ankylosis, and has not described functional limitations of ankylosis, even during flare-ups.  The Court, citing Dorland's Illustrated Medical Dictionary (28th ed. 1994), has recognized that ankylosis is defined as "immobility and consolidation of a joint due to disease, injury or surgical procedure," for VA compensation purposes.  See Colayong v. West, 12 Vet. App. 524, 528 (1999); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995).  In this case, the evidence of record, both lay and medical, does not reveal ankylosis of the right wrist or a disability picture that more nearly approximates immobility and consolidation (ankylosis) of the right wrist.

As noted above, the Veteran, through the representative, contends that he has flare-ups of the right wrist as indicated in the December 2013 VA examination.  See December 2014 Notice of Disagreement.  During the December 2013 VA examination, the Veteran described the impact of the flare-ups as a right wrist that hurts daily, and bending the wrist forward causes pain.  Immediately following this explanation of right wrist flare-ups, the Veteran also explicitly reported that there is no pain, weakness, fatigability, or incoordination that significantly limits functional ability when the joint is used repeatedly over a period of time.

Based on the above, the degree of functional impairment does not warrant a higher rating than 10 percent based on limitation of motion for the right wrist disability.  As such, the Board finds that an increased disability rating in excess of 10 percent is not warranted under Diagnostic Code 5214 (ankylosis of the wrist) for the right wrist disability.

In addition, there are no residual surgical scars or other right wrist scars associated with the right wrist disability.  Further, the Veteran has not undergone a total right wrist replacement; therefore, Diagnostic Code 5053 does not apply.  In short, upon a complete review of the evidence, the Board finds that the Veteran is not entitled an increased rating in excess of 10 percent for the right wrist disability for any period.  Without evidence of ankylosis of the right wrist joint, there are no other rating criteria that would afford the Veteran a rating in excess of 10 percent.  See 
38 C.F.R. § 4.71a, Diagnostic Code 5214.  

The Board acknowledges the Veteran's statements that the right wrist disability warrants a higher rating.  However, in determining the actual degree of disability, in this case, an objective examination that is administered by a trained medical professional is more probative of the degree of the Veteran's impairment.  Furthermore, the opinions and observations of the Veteran alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of the service-connected right wrist disability.  See Moray v. Brown, 2 Vet. App. 211, 214 (1993); see also 38 C.F.R. § 3.159(a) (2015).

The Board finds the evidence of record supports the conclusion that the Veteran is not entitled to an increased rating during any time within the increased rating period on appeal.  For these reasons, the Board finds that an increased rating in excess of 10 percent for a right wrist disability is not warranted for any appeal period.  Because the preponderance of the evidence is against the appeal, the benefit of the doubt doctrine is not for application, and the appeal must be denied.  See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Initial Rating for Right Leg Residual Scars

For the entire increased rating period, the evidence of record, lay and medical, is at least in equipoise as to whether the residual scars of the right leg have been manifested by pain.  Diagnostic Code 7800 rates scars of the head, face, or neck based upon disfigurement, so does not apply in this case as the right leg residual scars are not located on the head, face, or neck.  38 C.F.R. § 4.118.  Under Diagnostic Code 7801, scars other than on the head, face, or neck that are deep or cause limited motion are rated as 10 percent disabling for areas exceeding 6 square inches (sq. in.) (39 square centimeters (sq. cm.), 20 percent disabling for areas exceeding 12 sq. in. (77 sq. cm.), 30 percent disabling for areas exceeding 72 sq. in. (465 sq. cm.), and 40 percent disabling for areas exceeding 144 sq. in. (929 sq. cm.).  Note (2) under Diagnostic Code 7802 provides that a deep scar is defined as one associated with underlying soft tissue damage. 

Under Diagnostic Code 7802, a 10 percent rating is warranted for superficial scars that do not cause limited motion, in an area or areas of 144 sq. in. (929 sq. cm.) or greater.  Note (2) under Diagnostic Code 7802 provides that a superficial scar is defined as one not associated with underlying soft tissue damage.  Under Diagnostic Code 7803, a 10 percent rating is warranted for superficial and unstable scars.  Note (1) under Diagnostic Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 

Diagnostic Code 7804 provides for a 30 percent rating for five or more scars that are unstable or painful, a 20 percent rating for three or four scars that are unstable or painful, and a 10 percent rating for one or two scars that are unstable or painful.  An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.  Note (1).  If one or more scars are both unstable and painful, add 10 percent to the rating that is based on the total number of unstable or painful scars.  Note (2).  Scars rated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive a rating under this diagnostic code, when applicable.  Note (3).  38 C.F.R. § 4.118.  According to Diagnostic Code 7805, other scars are to be rated based on the limitation of function of the affected body part.

The Veteran underwent a VA scars examination in August 2009.  At that time, the Veteran insisted upon having three discrete wounds, which the VA examiner indicated he could not visualize.  Upon close scrutiny, the VA examiner observed two hypopigmented areas in the midsection of the posterior right leg, below the insertion of the calf.  They were both hypopigmented, non-depressed areas with 0.5 centimeters in diameter.  The VA examiner indicated that he could not visualize the third scar the Veteran identified.  The VA examiner also noted the Veteran's report that the scars have been tender; however, the VA examiner further noted that the Veteran could touch the areas with a ballpoint pen with no difficulty.  The scars were not depressed or elevated.  There was no keloid formation or skin breakdown.  The VA examiner noted that there was no underlying soft tissue injury, edema, or any observable deformity, and the scars did not limit motion or function.

In this case, the Veteran has repeatedly contended that the right leg residual scars are painful.  He is competent to testify regarding observable symptoms, such as pain associated with a scar, because this requires only personal knowledge as it comes to him through his senses.  See Layno v. Brown, 6 Vet. App. 465, 469 (1994).  In addition, the Veteran has been consistent throughout the claim and appeal process with respect to the right leg residual scars.  Consistent with the Veteran's report (including during the August 2009 VA examination) that the scars have been tender, in the June 2010 Notice of Disagreement, the Veteran again stated that the scars are sensitive to the touch.  The Veteran further explained that the August 2009 VA examiner was inaccurate in recording that the Veteran could touch the scar areas with a ballpoint pen without difficulty.  In the June 2010 Notice of Disagreement, the Veteran contended that it hurt when the August 2009 VA examiner touched the affected areas of scars.  

For these reasons and resolving reasonable doubt in the Veteran's favor, for the entire increased rating period, the residual scars of the right leg have been manifested by tenderness.  As to the amount (number) of residual scars of the right leg, as noted above, the VA examiner could only visualize two residual scars despite the Veteran's insistent identification of three scars.  The Veteran underwent a VA examination in December 1994, which is outside of the increased rating appeal period for rating purposes.  While the Board acknowledges that the December 1994 VA examination is years prior to the increased rating period on appeal, the December 1994 VA examination is helpful in determining the number of residual scars associated with the right leg.  See 38 C.F.R. §§ 4.1, 4.2.  At the time of the December 1994 VA examination, upon physical examination, the VA examiner indicated that there are two, one-centimeter scars, over the left lower leg.  Given the consistency of two VA examiners who evaluated the Veteran at two separate times, and who both observed only two residual scars of the right leg, the Board finds that the Veteran has two, painful right leg residual scars.  As such, an increased rating of 10 percent, but no higher, under Diagnostic Code 7804 for two, painful, residual scars of the right leg for the entire increased rating period is warranted.

An increased rating in excess of 10 percent for each of the right leg residual scars is not warranted for any part of the increased rating period.  As noted above, the scars are not of the head, face or neck; therefore, Diagnostic Code 7800 is not applicable.  The scars have been shown to be no more than one square centimeter; therefore, a compensable rating is also not warranted under Diagnostic Codes 7801 or 7802.  The August 2009 VA examiner did not indicate, and the Veteran has not contended, that the scars were unstable; therefore, a compensable rating is not warranted under Diagnostic Code 7804 for unstable scars.  Finally, the evidence of record does not indicate that the scars are productive of limitation of function; therefore, a compensable rating is not warranted under Diagnostic Code 7805.

Extraschedular Consideration

The Board has considered whether referral for extraschedular consideration is warranted.  An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards.  38 C.F.R. § 3.321 (b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993).

Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating.  First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating.

The Board finds that all the symptomatology and impairment caused by the Veteran's right wrist disability are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required at any time during the increased rating appeal period.  The Veteran's symptom of painful limitation of motion was considered when awarding the schedular rating for the right wrist disability under Diagnostic Code 5215 for the entire increased rating period on appeal.  This symptom is part of, similar to, and approximates, the symptom of limited range of motion, which include limitations of motion due to orthopedic (DeLuca) factors such as pain on movement, stiffness, and tenderness to palpation.  As discussed above, painful limitation of motion is specifically considered under the schedular rating criteria.  See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca at 202 (additional limitation of motion due to orthopedic factors are part of the schedular rating criteria).  Particularly, these symptoms and functional impairment were considered when awarding the 10 percent schedular rating under Diagnostic Code 5215.  Therefore, the symptoms and/or manifestations and functional impairment related to the right wrist disability are fully contemplated and adequately compensated by the schedular rating under Diagnostic Code 5215 for the entire increased rating period on appeal.

In this case, the right wrist disability manifested symptoms and functional impairment including limitation of motion and pain.  The Veteran also reported experiencing pain of the right wrist if he attempts to lift an object or if he turns the right wrist, which is indicative of the severity of the symptoms such as limitation of motion and pain, thus providing additional evidence to assist in determining how much the Veteran's right wrist motion is limited, and the additional impairment caused by the right wrist disability, as allowed and instructed by DeLuca.  Accordingly, the Board finds that the schedular rating criteria are adequate to rate the right wrist disability symptoms and functional impairment that limits motion.

The symptomatology and impairment caused by the Veteran's right leg residual scars are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required at any time during the increased rating appeal period.  The schedular rating criteria, Diagnostic Code 7804, specifically provide for disability ratings based on painful scars.  Considering the lay and medical evidence, the two residual scars of the right leg are characterized by scars that are no more than 1.5 square centimeter and scars that are painful.  In this case, comparing the Veteran's disability level and symptomatology of the right leg residual scars to the rating schedule, the degree of disability throughout the entire increased rating period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate.

The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations.  38 U.S.C.A. § 1155.  "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability."  38 C.F.R. § 4.1.  In this case, the symptoms reported by the Veteran regarding the service-connected right wrist disability and right leg residual scars are specifically contemplated by the criteria discussed above, including the effect of the Veteran's symptoms on occupation and daily life.  In the absence of exceptional factors associated with a right wrist disability or right leg residual scars, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321 (b)(1) are not met.  See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). 

According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321 (b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations."  Referral for an extraschedular rating under 38 C.F.R. § 3.321 (b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities.  In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate.  Also, the issue of a TDIU, which is another form of extraschedular rating with different criteria, is addressed in the Remand section below.

Reopening of Service Connection for PTSD and a Left Ankle Disorder

Generally, a claim which has been denied in a final unappealed rating decision, or a rating decision that was appealed but was not perfected, may not thereafter be reopened and allowed.  38 U.S.C.A. § 7105 (c), (d)(3); 38 C.F.R. § 20.1103.  If "new and material" evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim.  38 U.S.C.A. § 5108; 38 C.F.R. § 3.156 (a).  "[N]ew evidence" means evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial.  38 C.F.R. § 3.156 (a).  Materiality has two components, first, that the new evidence pertains to the reason(s) for the prior final denial, and second, that the new evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim.  Shade v. Shinseki, 24 Vet. App. 110, 117 (2010).  When making a determination whether the submitted evidence meets the definition of new and material evidence, the Board should take cognizance of whether that evidence could, if the claim were reopened, reasonably result in substantiation of the claim, applying concepts derived from the duty to assist.  Id., at 118.  In determining whether evidence is new and material, the credibility of the evidence is presumed.  See Justus v. Principi, 3 Vet. App. 510, 513 (1992).

The Veteran seeks to reopen service connection for PTSD and a left ankle disorder.  The original claims, initially filed in October 1994, were denied in a March 1995 rating decision.  The Veteran did not initiate an appeal of the decisions denying service connection for PTSD and a left ankle condition, and he also did not submit any new and material evidence with respect to these claims within the applicable one-year period.  See 38 C.F.R. § 3.156(b); Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007).  As such, the decision denying service connection for PTSD and a left ankle condition became final as to the evidence then of record, and is not subject to revision on the same factual basis.  38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103.

In the March 1995 rating decision, the RO denied service connection for PTSD and a left ankle condition on the basis that there was no confirmed diagnosis of PTSD and there was no chronic condition involving the left ankle.  The evidence before the RO at the time of the March 1995 rating decision included service treatment records, a December 1994 VA examination, and lay statements.

The Veteran attempted to reopen service connection for PTSD.  A September 1996 rating decision continued the denial of service connection for PTSD, finding that the evidence submitted did not establish a current diagnosis of PTSD.  At that time, the evidence before the RO (in addition to that already of record as listed in the March 1995 rating decision) consisted of an August 1996 VA examination and VA treatment records.  

A January 1997 rating decision continued the denial of service connection for PTSD, finding that the evidence submitted did not establish a current diagnosis of PTSD.  At that time, the evidence before the RO consisted of additional VA treatment records.  The Veteran was notified of the January 1997 rating decision and was provided notice of procedural and appellate rights that same month.  The Veteran did not disagree with the determination within one year of that notice.  No additional new and material evidence was received within one year of the January 1997 notice.  For these reasons, the January 1997 rating decision became final.  38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.302, 20.1103.

Evidence received since the March 1995 rating decision (last final disallowance for service connection for a left ankle condition) includes VA treatment records and a September 2005 private medical evaluation from Dr. N.P.  The VA treatment records and Dr. N.P.'s private medical evaluation are new because they have not been previously submitted.  Evidence received since the January 1997 rating decision (last final disallowance for service connection for PTSD) includes VA treatment records, to include a July 2009 letter with psychiatric evaluation from the Veteran's treating VA psychiatrist, Dr. K.M., a January 2016 private medical opinion from M.M., and VA examinations.  The VA treatment records, Dr. K.M.'s psychiatric evaluation, M.M.'s private medical opinion, and VA examinations are new because they have not been previously submitted.  

This evidence (for both service connection for PTSD and a left ankle condition) is also material because it pertains to the basis for the prior denial, that is, a current diagnosis of PTSD and a left ankle disorder, so raises a reasonable possibility of substantiating the claims.  Specifically, in numerous VA treatment records, particularly in February and March 2011, the Veteran was diagnosed with PTSD.  In a July 2009 letter, the Veteran's treating VA psychiatrist, Dr. K.M., indicated that the Veteran is receiving care for PTSD and is able to perform work within limitations caused by his symptoms.  In an associated Doctor's Certificate from July 2009, Dr. K.M. indicated that the Veteran had PTSD due to trauma witnessed while serving in the military.  Also, in a March 2011 VA treatment record, the Veteran reported a history of a left ankle injury in service and indicated that he uses a cane for walking.  In Dr. N.P.'s medical evaluation report, the Veteran's left ankle frequently swells, and the Veteran wraps the left ankle in ace bandages and utilizes braces.  While the history of a left ankle injury in service was already of record during the March 1995 final disallowance, the use of a cane for walking, the use of braces and ace bandages to wrap the left ankle, and left ankle swelling are both new and material as they suggest additional symptoms of a left ankle disorder.  

For these reasons, the Board finds that new and material evidence has been received to reopen service connection for PTSD and a left ankle condition.  See 38 C.F.R. § 3.156 (a).  The reopened issue of service connection for PTSD is adjudicated below, and the reopened issue of service connection for a left ankle condition is addressed in the Remand section below.

Service Connection - Laws and Regulations

Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Service connection may 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).  As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). 

In this case, PTSD, trichotillomania, and asthma are not "chronic diseases" listed under 38 C.F.R. § 3.309(a).  In addition, the Veteran is not currently diagnosed with any right arm disability (other than the right wrist) or heart disability.  Because PTSD, trichotillomania, and asthma are not chronic diseases, and the Veteran has no diagnosed right arm or heart disability, it necessarily follows that there is no "chronic disease" under 38 C.F.R. § 3.309(a) for which the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service would be applicable.  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 

To establish presumptive service connection for a disease associated with exposure to certain herbicide agents, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service, the veteran must show the following: (1) that he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; (2) that he currently suffers from a disease associated with exposure to certain herbicide agents enumerated under 38 C.F.R. § 3.309(e); and (3) that the current disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii).  38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e).  If a veteran was exposed to an herbicide agent during active military, naval, or air service, the certain diseases shall be service-connected, if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service.

Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor.  38 C.F.R. § 3.304(f) (2015).  

Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation.  38 U.S.C.A. § 1154(a) (West 2015); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence).  The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").

When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 49.

Combat Rule

In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation.  See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996).  The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor.  See VAOPGCPREC 12-99.  The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder.  See Libertine, 9 Vet. App. at 522-23.  The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service.  Clyburn v. West, 12 Vet. App. 296, 303 (1999).

In this case, the evidence supports the finding that the Veteran engaged in combat with the enemy during service.  In particular, the Veteran's service records document his involvement in combat during the Vietnam War, as evidenced by receipt of the Purple Heart medal.  Based on this evidence, the Board finds that the Veteran engaged in combat with the enemy during service, and the combat rule is applicable.  38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d).

Service Connection for PTSD and Trichotillomania

The Veteran contends that PTSD and trichotillomania are a result of in-service stressors experienced in Vietnam.  Specifically, the Veteran reports being shot by small arms fire during a flight mission to Vietnam where he was wounded by shrapnel.  See February 2013 VA PTSD Examination Report.  The Veteran also reports losing three close friends in Vietnam.  See March 2016 Correspondence.  

As discussed above, the Board finds that the Veteran engaged in combat with the enemy during service.  The DD Form 214 shows receipt of a Purple Heart medal; therefore, the Board finds that the presumption afforded combat veterans under 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(f)(2) is applicable, and the Veteran's lay account of losing close friends in Vietnam and being shot by small arms fire during a flight mission to Vietnam are sufficient to establish the occurrence of the claimed in-service stressor events.

The Board next finds that the relevant lay and medical evidence reflects that the Veteran has current acquired psychiatric disabilities of PTSD and trichotillomania.  In February and March 2011 VA treatment records, after two separate comprehensive psychiatric evaluations by two different VA mental health professionals (chief physician of mental health service and a clinical psychologist), the Veteran was assessed with an Axis I diagnosis of PTSD.  In this regard, a PTSD diagnosis provided by a mental health professional must be presumed to have been made in accordance with the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as to both the adequacy of the symptomatology and the sufficiency of the stressor, unless there is evidence to the contrary.  See Cohen v. Brown, 10 Vet. App. 128, 140 (1997).  As such, the Board finds that the February and March 2011 diagnoses of PTSD satisfies 38 C.F.R. § 4.125 (a) (2015).  

A July 2009 Doctor's Certificate from the Veteran's treating VA psychiatrist, 
Dr. K.M., revealed a diagnosis of trichotillomania.  Trichotillomania is defined as "compulsive pulling out of one's hair, associated with tension or an irresistible urge before pulling and following by pleasure or relief."  See Dorland's Illustrated Medical Dictionary 1991 (31st ed.2007).  In addition, numerous VA treatment records reflect complaints of hair pulling and a diagnosis of trichotillomania.  See December 2011 VA Treatment Record. 

The Board further finds that the evidence shows that both the diagnosis of PTSD and diagnosis of trichotillomania were competently linked to the in-service combat stressor events by a competent medical professional.  As mentioned above, a July 2009 Doctor's Certificate from the Veteran's treating VA psychiatrist, Dr. K.M., indicated that the Veteran had PTSD due to trauma witnessed while serving in the military.  In a January 2016 private medical opinion, M.M., a mental health professional, also opined that it is more likely than not that the PTSD resulted from the trauma during service in Vietnam.  M.M. also opined that, based on the history of combat trauma, it is more likely than not that exacerbation of the symptoms of trichotillomania were caused by those experiences.  

For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for PTSD under 3.304(f)(2) and trichotillomania have been met.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.  When implementing this Board decision to grant service connection for an acquired psychiatric disorder, to include PTSD and trichotillomania, the RO will rate the PTSD together with the trichotillomania to provide one rating based on all the Veteran's psychiatric impairments.  The General Formula for Rating Mental Disorders at 38 C.F.R. § 4.130 provides that all service-connected psychiatric disabilities and symptoms, including PTSD and trichotillomania symptoms, are to be rated together.  Thus, the Veteran would not be entitled to separate ratings for symptoms of trichotillomania and PTSD as 38 C.F.R. § 4.14 provides that rating such manifestations of a disability under multiple diagnoses (i.e., pyramiding) is to be avoided.  See VAOGCPREC 23-97; see also Esteban v. Brown, 6 Vet. App. 259 (1994) (holding that a separate rating may be granted for a "distinct and separate" disability that is, "when none of the symptomatology . . . is duplicative . . . or overlapping.").  That is, a claimant may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity."  Brady v. Brown, 4 Vet. App. 203, 206 (1993).

Service Connection for Asthma

The Veteran asserts that he has asthma and that it is related to the presumed exposure to herbicides in Vietnam, as well as smoke inhalation during brushfires.  

In this case, the Veteran is diagnosed with asthma.  See August 2009 VA examination report.  Also, the Veteran served in the Republic of Vietnam during the Vietnam Era and is in receipt of the Purple Heart medal; therefore, he is presumed to have been exposed to herbicides.  38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii).  As asthma is not one of the presumptive diseases for herbicide exposure, there is no presumption of service connection based on herbicide exposure for the claimed asthma.  See 38 C.F.R. § 3.309(e); see also Notice, 
75 Fed. Reg. 32540-03 (2010).

Regardless, in Combee v. Brown, the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis.  Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993).  As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, see 38 C.F.R. § 3.309(e), but must also determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d).

After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is at least in equipoise on the question of whether the asthma is causally related to in-service exposure to herbicide agents and smoke inhalation.  In support of the Veteran's claim, in a March 2016 letter, a private physician, Dr. A.A., noted that the Veteran was exposed to multiple pulmonary irritants in service such as Agent Orange and smoke.  Citing to medical literature, Dr. A.A. indicated that such exposure can cause irritation to the lungs and development of asthma.  Since the Veteran was exposed to multiple irritants while in service, Dr. A.A. opined that it is more likely than not that the cumulative effects of the multiple lung irritants that the Veteran was exposed to in service led to the development of the adult onset asthma.

Dr. A.A.'s opinion is competent and probative medical evidence because it is factually accurate, as it appears Dr. A.A. had knowledge of the relevant evidence in this case, relied on accurate facts, and gave fully articulated impressions and opinions.  There is no other competent medical opinion of record against the claim which directly addresses the etiology of the Veteran's asthma.  For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for asthma on a direct basis, as related to exposure to herbicides and smoke inhalation in service, have been met.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.

Service Connection for Residuals of a Broken Right Arm and a Heart Disorder

The Veteran contends that he has problems with the right arm as a residual of a broken right arm (other than a right wrist disability) and heart problems, and has particularly complained of right arm pain and chest pain.  

After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding of a current right arm disability (other than a right wrist disability) and a heart disability.  

In December 2011, the Veteran underwent a VA elbow and forearm examination.  There, the Veteran reported that he had a closed fracture of the distal radius and ulnar styloid process.  In this regard, the Board notes that the Veteran is service connected for a right wrist disability (the appeal for an increased rating for a right wrist disability is adjudicated above).  The VA examiner explained that this is a common fracture, which often presents with a dislocation requiring closed reduction.  Ultimately, the VA examiner opined that there has not been, nor is there currently, any right forearm or elbow abnormality.

The Veteran was afforded a VA heart examination in March 2016.  The VA examiner considered the Veteran's claimed angina.  Indeed, the March 2016 VA examiner noted a September 2005 VA treatment record when the Veteran complained of daily angina pain.  However, the March 2016 VA examiner explained that the Veteran has a diagnosis of atypical chest pain, and not angina.  In support of this finding, the VA examiner noted the normal test results from a dipyridamole infusion test, a myocardial perfusion study, and a multiple myocardial perfusion study.  

In this case, while the Veteran has competently complained of right arm pain and chest pain, there is no current right arm or heart "disability" other than the service-connected right wrist disability.  See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. West, 239 F.3d 1356, 1361-62 (Fed. Cir. 2001).

The existence of a current disability is the cornerstone of a claim for VA disability compensation.  See Degmetich v. Brown, 104 F. 3d 1328 (1997).  Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection.  See 38 U.S.C.A. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability).  "In the absence of proof of a present disability there can be no valid claim."  See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  Service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present.  McClain v. Nicholson, 21 Vet. App. 319 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that that, when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency).

Although the Veteran has at least implicitly asserted that he experiences symptoms that are attributable to diagnoses of a right arm disability and a heart disability, he is a lay person and, under the facts of this case, he does not have the requisite medical expertise to diagnose either a right arm or heart disability, or render an opinion as to the etiology of such symptoms claimed to be these.  In the present case, the Board finds heart disorders to be too medically complex to be diagnosable based solely on lay observation and testimony.  See 75 Fed. Reg. 53,202 (August 31, 2010) (stating examples of diagnosed IHD such as acute, sub-acute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina).  While the Veteran is competent to testify regarding such observable symptomatology as chest pain, an actual diagnosis of a heart disability is based on internal observations of the cardiovascular system, and specific clinical findings.  See also Woehlart v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a disorder capable of lay diagnosis).

Similarly, an opinion as to diagnosis and causation of a right arm disorder involves making findings based on medical knowledge and clinical testing results, and the musculoskeletal system is complex and often involve unseen systems processes and disease processes that are not observable by the five senses of a lay person.  See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (holding that ACL injury is too "medically complex" for lay diagnosis); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury).

The Veteran has also not reported contemporaneous medical diagnoses by a competent source, and his symptoms (right arm pain and chest pain) have not later been supported by diagnoses rendered by a medical professional.  See Jandreau, 492 F.3d at 1372.  Consequently, the Veteran's purported opinions relating the reported right arm pain and chest pain to diagnoses of a right arm disability (other than a right wrist disability) and a heart disability are of no probative value.

In this case, the weight of the evidence is against finding a right arm or heart disability at any point during the claim period, including prior to the filing of the claims for service connection.  For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran does not have currently diagnosed heart or right arm disabilities other than a right wrist disability.  As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application, and the appeals must be denied.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.

Service connection for a Dental Disorder for VA Compensation

An appeal of service connection for a dental disorder for the purpose of obtaining VA compensation (claimed as tooth trauma) was certified to the Board; however, the RO erred in adjudicating and denying the claim for a dental condition, tooth trauma, in the December 2013 rating decision, and instead should have informed the Veteran that service connection is already in effect for this disability, which was granted in a March 1979 dental rating decision.  The body of the March 1979 dental rating decision (dental rating sheet) specifically indicates that the trauma to tooth 10 was incurred or aggravated in service.  The AOJ must acknowledge the fact that service connection is already in effect for a dental disorder due to trauma in the rating code sheets by removing this condition from the list of disabilities not service connected and adding the term "dental disability, to include trauma to tooth 10."  

Accordingly, the appeal of the denial of service connection for a dental disorder for the purpose of obtaining VA compensation (claimed as tooth trauma) is dismissed, as it concerns a disability for which service connection has already been established; therefore, there remains no case or controversy regarding this issue.  See 38 U.S.C.A. § 7105(d).


ORDER

An increased disability rating in excess of 10 percent for a right wrist disability is denied.

For the entire increased rating period on appeal, a 10 percent disability rating for two residual scars of the right leg is granted.

As new and material evidence has been received, the appeal to reopen service connection for PTSD is granted.

As new and material evidence has been received, the appeal to reopen service connection for a left ankle disorder is granted.

Service connection for PTSD is granted.

Service connection for an acquired psychiatric disability other than PTSD, to include trichotillomania, is granted.

Service Connection for asthma, to include as due to Agent Orange (herbicide) exposure and smoke inhalation, is granted.

Service connection for residuals of a broken right arm (other than a right wrist disability) is denied.

Service connection for a heart disorder, to include as due to exposure to herbicides including Agent Orange, is denied.

As service connection is already in effect for service connection for a dental disorder, for the purpose of obtaining VA compensation, the appeal is dismissed.


REMAND

A remand is required in this case to ensure that there is a complete record upon which to decide the appeals of service connection for an acquired psychiatric disability other than PTSD, to include Tourette Syndrome, a left ankle disorder, neurological problems, residuals of a left leg fracture, a spinal disorder, and a burn of the right ankle, aid and attendance allowance for the Veteran's spouse, a TDIU, an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability, and a noncompensable dental disorder.  VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim.  38 U.S.C.A. § 5103A(a) (West 2014); 38 C.F.R. § 3.159(c), (d) (2015).

Service Connection for Tourette Syndrome, a Left Ankle Disorder, Neurological Problems, and a Spinal Disorder

The Veteran contends that Tourette Syndrome, a left ankle disorder, neurological problems, and a spinal disorder are due to service.  Specifically, the Veteran contends that Tourette Syndrome is due to combat trauma and/or a residual of trauma during two motorcycle accidents during service.  He also contends that the left ankle disorder, neurological problems, and a spinal disorder are due to the two motorcycle accidents experienced during service.

As noted above, the Veteran engaged in combat with the enemy during service and experienced combat trauma.  Also, service treatment records reveal that the Veteran had two separate motorcycle accidents in March 1972 and September 1972.

Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide a claim.  38 C.F.R. § 3.159(c)(4)(i) (2015).  A medical examination or medical opinion may be deemed necessary where the record contains competent evidence of a current disability or recurrent symptoms of a disability, establishes that the veteran suffered an event, injury, or disease in service, and indicates that the claimed disability may be associated with the established event, injury, or disease in service.  See Id; McLendon v. Nicholson, 
20 Vet. App. 79 (2006).  

Here, while it is unclear whether the Veteran is currently diagnosed with Tourette Syndrome, a left ankle disorder, a neurological disorder, and a spinal disorder, the evidence reveals complaints of twitching, left ankle pain and swelling with the use of an assistive device and braces, headaches, and neck and back pain.  A VA examination was not conducted and there is no other medical opinion of record regarding the etiology of Tourette Syndrome, a left ankle disorder, neurological problems, or a spinal disorder.  As such, the Board finds that a VA examination is warranted to assist in determining the diagnosis and etiology of any current Tourette Syndrome, left ankle disorder, neurological disorder, and spinal disorder.  McLendon, 20 Vet. App. at 79.


Service Connection for Residuals of a Left Leg Fracture 
and a Burn of the Right Ankle

In a December 1997 VA examination report, the Veteran indicated that he sustained a "tib-fib fracture" of the left leg as a result of a football injury in 1977.  Consistent with this report, in a March 2011 VA treatment record, the Veteran indicated that he had a compound fracture of the left tibia/fibula during service due to a football injury in 1977.  Similarly, the Veteran contends that he sustained third degree burns on the right ankle due to a kitchen fire during service in 1989.  See February 2011 VA Form 21-526 (Application for Compensation and/or Pension).  The record suggests that the Veteran had additional active service from June 1974 to June 1977.  See March 1995 Rating Decision.  However, the record only includes a 
DD 214 for the active duty periods of June 1971 to December 1973.  In light of the Veteran's contention indicating in-service injuries to the left leg (a left tibia/fibula fracture) and an in-service burn of the right ankle during outstanding periods of unverified active service, the Board finds that a remand is necessary in order for VA to attempt to obtain the Veteran's complete service personnel and treatment records and attempt to verify all periods of active service.

Aid and Attendance Allowance for the Veteran's Spouse

A veteran's spouse will be considered in need of regular aid and attendance if she/he: (1) is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or 
(3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352 (a) (inability to dress/undress, or to keep ordinarily clean/presentable; frequent adjustment of special prosthetic/orthopedic appliances with the aid of another; inability to feed self; inability to attend to wants of nature; or incapacity, physical or mental, that requires assistance on a regular basis to protect from hazards/dangers incident to daily environment).  38 C.F.R. § 3.351(c) (2015).

The record is unclear as to whether the Veteran's claimed spouse, T.M.M., meets the criteria for spousal aid and attendance as there is a lack of evidence showing a valid marriage under the law.  Indeed, while there is a Marriage Certificate of record, dated in August 1978, the bride's name is different than that of the Veteran's currently claimed spouse.  In addition, in a VA treatment report from August 2014, the Veteran reported that his spouse died in September 2010; however, quarterly social worker reports prior to January 2015 indicate the presence of a spouse or significant other in the Veteran's household.  Significantly, pursuant to the VCAA, the RO did not advise the Veteran of what the evidence must show to establish entitlement to an aid and attendance allowance for a spouse, and did not describe the types of information and evidence that the Veteran needed to submit to substantiate the claim.  Accordingly, a Remand is necessary for VCAA notice and development of additional evidence needed to assist in deciding the claim of entitlement to an aid and attendance allowance for a spouse.

Earlier Effective Date for Increased Rating for a Right Wrist Disability

In a December 2013 rating decision, the RO awarded an increased rating of 10 percent for the service-connected right wrist disability (the appeal of an increased rating in excess of 10 percent for a right wrist disability is adjudicated in the decision above).  In a December 2014 submission (via VA Form 21-0958), received within one year of notification of the December 2013 rating decision, the Veteran expressed disagreement with the December 2013 rating decision, specifically, with the 10 percent disability rating (adjudicated above) and the effective date of the award of an increased rating of 10 percent for a right wrist disability.  

The appeal of an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability should be remanded to allow the RO to provide a Statement of the Case on this issue.  Manlincon v. West, 12 Vet. App. 238, 240-41 (1999).  However, the issue will be returned to the Board after issuance of the Statement of the Case only if perfected by the filing of a timely Substantive Appeal.  See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997).

Service Connection for a Noncompensable Dental Disorder for Treatment Purposes

The Board must address all issues reasonably raised by a liberal reading of the record; consistent with this principle, a claim for service connection for a dental condition for purposes of compensation must also be considered to be a claim for service connection for a dental disability for purposes of VA outpatient dental treatment.  See Mays v. Brown, 5 Vet. App. 302 (1993).  The Board further notes that, as to each noncompensable service-connected dental condition, a determination will be made regarding whether it was due to combat wounds or other service trauma.  38 C.F.R. § 3.381(b).  The significance of finding a dental condition is due to service trauma is that a veteran will be eligible for VA outpatient dental treatment without being subject to the usual restrictions of a timely application and one-time treatment.  38 C.F.R. § 17.161(c).

The regulation relating to service connection of dental conditions for treatment purposes was amended, effective February 29, 2012, in order to clarify existing regulatory provisions and to reflect the respective responsibilities of the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) in determinations concerning eligibility for dental treatment.  See Proposed Rules, Dental Conditions, 76 Fed. Reg. 14,600 (Mar. 17, 2011); Final Rule, Dental Conditions, 77 Fed. Reg. 4469 (Jan. 30, 2012).  The amended version of 38 C.F.R. § 3.381 clarifies that VBA will adjudicate a claim for service connection of a dental condition for treatment purposes after the VHA determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests that VBA make a determination on relevant questions.  38 C.F.R. § 3.381(a) (2015).

In this case, the RO did not refer the claim of service connection for a dental disability for purposes of VA outpatient treatment purposes.  As such, the Board finds that a remand is appropriate here.  A remand with instructions to the RO to refer the claim to the VHA, which the regulation provides must make the initial determination on the claim, will better ensure that the claim is addressed promptly and efficiently, and is, therefore, consistent with the uniquely pro-claimant principles underlying the veterans' benefits system.  Nat'l Org. of Veterans Advocates, Inc. v. Sec'y of Veterans Affairs, 710 F.3d 1328, 1330 (Fed. Cir. 2013).

Entitlement to a TDIU

In the decision above, the Board has granted an increased disability rating for service-connected right leg residual scars, and granted service connection for PTSD, trichotillomania, and asthma.  The RO adjudicated the issue of a TDIU in a December 2013 rating decision.  Service-connected right leg residual scars were not rated at 10 percent disabling, and PTSD, trichotillomania, and asthma were not service connected at the time of the December 2013 adjudication; therefore, the occupational impairment associated with the (now service-connected) PTSD, trichotillomania, and asthma, and a higher rating of service-connected right leg residual scars was not considered by the RO in the earlier adjudication of a TDIU.  In light of the grant of an increased disability rating for service-connected right leg residual scars, and service connection for PTSD, trichotillomania, and asthma in this Board decision, the RO should reconsider the issue of a TDIU.  See 38 C.F.R. §§ 4.16, 4.25 (2015). 

Accordingly, the issues of service connection for an acquired psychiatric disability other than PTSD of Tourette Syndrome, a left ankle disorder, neurological problems, residuals of a left leg fracture, a spinal disorder, and a burn of the right ankle, aid and attendance allowance for the Veteran's spouse, a TDIU, an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability, and a noncompensable dental disorder are REMANDED for the following actions:

1. Provide a Statement of the Case as to the issue of an effective date earlier than February 28, 2011 for an increased disability rating of 10 percent for a right wrist disability.  The Veteran must file a timely and adequate Substantive Appeal in order to perfect an appeal of this issue to the Board.  See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b) (2015).  If a timely Substantive Appeal is not filed, the claim should not be certified to the Board.

2. Appropriate notice should be issued to the Veteran to inform him of how to establish entitlement to an aid and attendance allowance for a spouse, and to ensure compliance with all notice and assistance requirements set forth in the VCAA and its implementing regulations.  This letter should also advise the Veteran of the evidence necessary to substantiate the claim, as well as what evidence he is to provide and what evidence VA will attempt to obtain.

3. Refer the claim for dental treatment to the appropriate VA Medical Center (VAMC) of the VHA to determine if the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161.

4. Contact the National Personnel Research Center (NPRC) and/or other appropriate unit records depository and research agency and request the Veteran's complete service personnel and service records.  Specifically, request verification of all dates the Veteran served on active duty (in addition to the already-verified period of active duty from June 1971 to December 1973).  

As set forth in 38 U.S.C.A. § 5103A (b)(3) and 38 C.F.R. § 3.159(c)(2), continue efforts to locate such records until it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile.  The Veteran should be notified of any action taken.

5. After implementing the Board's decision to grant an increased disability rating for service-connected right leg residual scars, and to grant service connection for PTSD, trichotillomania, and asthma, and accomplishing any additional notification and/or development deemed warranted, if the combined schedular rating is less than 100 percent, the issue of a TDIU should be readjudicated in light of all the evidence of record, considering additional occupational impairment caused by the right leg scar residuals, PTSD, trichotillomania, and asthma, along with all other service-connected disabilities.  If a TDIU remains denied, the Veteran and representative should be furnished with an appropriate Supplemental Statement of the Case, and should be afforded the appropriate time period for response.

6. Schedule an appropriate VA examination to assist in determining whether there are current diagnoses, and the nature and etiology of any current Tourette Syndrome, left ankle disorder, neurological disorder, and spinal disorder.  Following a review of all relevant evidence from the claims file, to include the electronic file on VBMS and Virtual VA, an interview with the Veteran to obtain a complete medical history (to include any relevant in-service and post-service injuries/diseases), an examination, and any necessary testing, the VA examiner is asked to offer the following opinions:

a) Does the Veteran have a current disability manifesting in twitching, to include, but not limited to, Tourette Syndrome?

If the Veteran does not have diagnosed Tourette Syndrome, the VA examiner should so state.

b) If the Veteran has a current disability of Tourette Syndrome, is it at least as likely as not (50 percent probability or greater) that the Tourette Syndrome began during service or is etiologically related to active service, to include as due to combat trauma and/or two motorcycle accidents in service?

c) Does the Veteran have a current disability manifesting in left ankle pain?

If the Veteran does not have a diagnosed disability manifesting in left ankle pain, the VA examiner should so state.

d) If the Veteran has a current disability manifesting in left ankle pain, is it at least as likely as not (50 percent probability or greater) that the left ankle disability began during service or is etiologically related to active service, to include two motorcycle accidents in service?

e) Does the Veteran have a current neurological disability manifesting in headaches?

If the Veteran does not have a diagnosed neurological disability, the VA examiner should so state.

f) If the Veteran has a current neurological disability, is it at least as likely as not (50 percent probability or greater) that the neurological disability began during service or is etiologically related to active service, to include two motorcycle accidents in service?

g) Does the Veteran have a current spinal disability manifesting in back and neck pain?

If the Veteran does not have a diagnosed spinal disability manifesting in neck and back pain, the VA examiner should so state.

h) If the Veteran has a current spinal disability disability manifesting in neck and back pain, is it at least as likely as not (50 percent probability or greater) that the spinal disability began during service or is etiologically related to active service, to include two motorcycle accidents in service?

In rendering the requested opinions, the VA examiner should assume, as fact, that the Veteran is a combat veteran who was exposed to combat trauma and had two motorcycle accidents in March and September 1972 during active service.

For all of the above opinions, 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.

A rationale should be given for all opinions and conclusions rendered.  The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to these claims.

7. After completion of the above and any additional development deemed necessary, readjudicate the issues of service connection for an acquired psychiatric disability other than PTSD to include Tourette Syndrome, a left ankle disorder, neurological problems, residuals of a left leg fracture, a spinal disorder, and a burn of the right ankle, and aid and attendance allowance for the Veteran's spouse in light of all the evidence of record.  If the determinations remain adverse to the Veteran, he and the representative, if any, should be furnished with a Supplemental Statement of the Case.  An appropriate period of time should then be allowed for a response before the record is returned to the Board for further review.

The Veteran 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).


______________________________________________
J. PARKER
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs