Citation Nr: 1713402 Decision Date: 04/25/17 Archive Date: 05/04/17 DOCKET NO. 09-48 156 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased disability rating in excess of 20 percent for bilateral spondylosis with spondylolisthesis and degenerative disc disease of the lumbar spine at L5-S1. 2. Entitlement to an increased disability rating, currently rated as non-compensable, for sarcoma and associated skin condition of the left medial arm. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. A. Macek, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty in the United States Air Force from December 1982 to October 2004 during the Gulf War Era and Peacetime. The matter comes to the Board of Veterans' Appeals (Board) from a February 2008 rating decision by the Department of Veterans Affairs VA Regional Office (RO) in Houston, Texas, which denied an increased rating in excess of 20 percent for the Veteran's back disability and which denied a compensable rating for his sarcoma disability. Currently, the RO of record is located in Phoenix, Arizona. FINDINGS OF FACT 1. The Veteran's service-connected lumbar spine disability has been manifested by no worse than forward flexion to 55 degrees without manifestation of abnormal gait, spine contour, kyphosis, or incapacitating episodes due to intervertebral disc syndrome (IVDS); the Veteran retained greater than 30 degrees of flexion when considering functional impairment; at no point has the associated radiculopathy of the lower extremities been more than moderate in severity in either extremity; the evidence weighs against a finding of other associated neurological disabilities, to include a bladder disability. 2. The Veteran's service-connected sarcoma of the left medial arm has not required treatment in the past 12 months and his residual skin condition covers less than 5 percent of his body, does not require systemic treatment, and does not produce any functional impairment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for bilateral spondylosis with spondylolisthesis and degenerative disc disease of the lumbar spine at L5-S1, with separate ratings for associated radiculopathies of the lower extremities, have not been met. 38 U.S.C.A. §§ 1155, 5107 (2014); 38 C.F.R. Part 4, including §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, § 4.115a, Diagnostic Codes 5243, 8520 (2016). 2. The criteria for a compensable rating for sarcoma of the left medial arm have not been met. 38 U.S.C.A. §§ 1155, 5107 (2014); 38 C.F.R. Part 4, including §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.21, 4.31, 4.40, 4.55, 4.56, 4.73, 4.118, Diagnostic Codes 5329, 7806 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2016). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2 (2016); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2016). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2016). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding, see 38 C.F.R. § 4.14 (2016), do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2016). Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thoracolumbar spine The general rating formula for diseases and injuries of the spine provides disability ratings based on range of motion, and considers associated neurologic abnormalities, unfavorable anklyosis, and intervertebral disc syndrome; additionally, a disability rating may be assigned under the factors prescribed under Deluca. A 10 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. Part 4, including 4.71(a). A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire (thoracolumbar and cervical) spine. Id. These ratings are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. Radiculopathy is rated under DC 8520 and categorized in terms of paralysis of the sciatic nerve. Paralysis may be considered as mild, moderate, moderately severe, or severe. The words "mild," "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2016). It should also be noted that use of such terminology by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2016). In June 2016, the Veteran reported that his back condition has become progressively worse. See June 2016 VA Form 21-4318. He contended that, because of his service connected thoracolumbar back condition, he suffers from sleep deprivation, poor range of motion, muscle spasms, bladder impairment due to neurologic abnormalities, memory loss and cognitive impairment due to lack of sleep, mood disorders due to lack of sleep, obesity, blood pressure elevation, and has developed a cervical neck condition, secondary to his lower back condition. He reported that he has missed days of work because it was recommended, by his doctor, to treat his back condition with bedrest. He indicated that he currently suffers from an overall poor quality of life. In December 2016, the Veteran's Service Organization provided an appellate brief to the Board seeking an increased rating on behalf of the Veteran. His representative argued that extraschedular consideration was warranted based on the Veteran's reported symptoms, which were not captured within the rating criteria for his service connected lumbar spine condition. Specifically, he cited functional loss, under Deluca, and asked that these factors be considered. The representative also argued for an independent medical opinion outside of VA to assess the severity of the Veteran's conditions, which he argues are in conflict with the evidence in the record. In terms of medical evidence, the Board notes that the RO increased the Veteran's rating for his back disability to 20 percent based on an August 2007 QTC examination. In this examination, range of motion on the thoracolumbar spine showed flexion to 55 degrees, extension to 10 degrees, right lateral flexion 20 degrees, left lateral flexion 20 degrees, right rotation 20 degrees, and left rotation 20 degrees. The combined range of motion of the thoracolumbar spine was 145 degrees. The examination was negative for evidence of radiating pain on movement, muscle spasm, and ankylosis of the lumbar spine. The Veteran appealed the RO's decision and was scheduled for a VA examination in December 2012. The examiner diagnosed the Veteran with lumbar degenerative disc disease with spondylosis and spondylothesis with intervertebral disc syndrome and discitis, resolved. Physical examination revealed range of motion of forward flexion to 70 degrees with painful motion, extension to 30 degrees with painful motion, right lateral flexion to 30 degrees with painful motion, left lateral flexion to 30 degrees with painful motion, right lateral rotation to 30 degrees with painful motion, and left lateral rotation to 30 degrees with painful motion. There was no further limitation after repetitive motions. There examiner noted that there were been no incapacitating episodes over the past 12 months due to IVDS. Based on the examination, a rating in excess of 20 percent was denied. In March 2013, a VA examination was conducted and the examiner diagnosed the Veteran with intervertebral disc syndrome of the L5-S1 region with lumbar degenerative disc disease with spondylosis and spondylothesis. In the examination, the Veteran reported flare-ups and described decreased mobility and being bedridden during pain episodes. Range of motion testing revealed flexion of the lumbar spine to 70 degrees with painful motion. There were no limitations of extension. Right lateral flexion was measured at 30 degrees with painful motion. Left lateral flexion was to 30 degrees with painful motion. Right lateral rotation was measured at 30 degrees with painful motion, left lateral rotation was measured at 30 degrees with painful motion, and the Veteran was able to perform repetitive motions without limitation. No incapacitating episodes due to IVDS were noted in the last 12 months. In September 2015, the Veteran presented to his private physician with low back pain. The Veteran reported that his chronic back pain became progressively worse in the past few months. He experienced pain and stiffness in his lower back, which became worse over the past few months. The pain was characterized as "crampy," with stiffness, and exhibiting some radiation down his legs bilaterally. Musculoskeletal exanimation results indicated no muscle or joint abnormalities with full range of motion in all four extremities. The back exhibited no costavertebral angle tenderness. He was diagnosed with unspecified thoracic or lumbosacral neuritis or radiculitis and prescribed medications to relieve spasm and pain. The Veteran was afforded a VA examination for his lumbar spine disability in March 2016. He was diagnosed with bilateral spondylosis with spondylolishthesis and degenerative disc disease at L5-S1. The Veteran's contentions noted that he has had chronic low back pain with symptoms that include constant moderate sharp aching lower back pain. Range of motion was measured at 80 degrees flexion, 30 degrees extension, 30 degrees for right lateral flexion, 30 degrees for left lateral flexion, with bilateral rotation at 30 degrees. The examination was negative for flare-ups, guarding, spasm, radiculopathy, ankyloses, neurologic abnormalities, scoliosis, reversed lordosis, or abnormal kyphosis, and IVDS. Functional loss was endorsed, which indicated that the Veteran's back was slightly limited in bending. The Board finds that reading this examination in its entirety that the examiner captured the functional limitations sufficient to determine that the Veteran retrained more than 30 degrees of flexion. The Veteran reported that his symptoms increased in severity while sitting and the condition prevented him from running. Range of motion of the thoracolumbar spine In order to meet the 40 percent disabling criteria, under DC 5243 of the general rating formula for diseases and injuries of the spine, forward flexion of the thoracolumbar spine must be limited to 30 degrees or less. Medical examinations have shown that the Veteran does experience limits in range of motion in his back with pain noted during bending. The most recent examination, in March 2016, indicated that the Veteran's forward flexion was measured at 80 degrees. Reviewing the medical evidence in the record indicates that the Veteran's forward flexion has not been limited to less than 30 degrees at any time, to include when fully considering the medical evidence regarding the impact of functional loss, to include pain, on the reduction in range of motion. Also, the examinations have been negative for ankylosis of the entire thoracolumbar spine. Since range of motion of the Veteran's thoraculombar spine has not been limited to 30 degrees or less, and he has not presented with ankyloses of the of the entire thoraculombar spine, a disability rating in excess of 20 percent, based on range of motion of the back, is not warranted. Intervertebral disc syndrome A higher disability rating may be assigned of there is the presence of an incapacitating episode caused by intervertebral disc syndrome (IVDS) as per §4.71a. A 10 percent rating may be assigned if incapacitating episodes are noted having a duration of at least one week, but less than two weeks during the past twelve months. Here, the March 2016 VA examination did not indicate the presence of intervertebral disc syndrome as a listed diagnosis. The Board notes that the Veteran reported that he has missed work on several occasions due to his back condition. However, Note 1 under DC 5243 rating defines an "incapacitating episode" "as a period of acute signs and symptoms due to IVDS that requires bedrest prescribed by a physician and treatment by a physician." The record indicates that the Veteran was diagnosed with IVDS of the thoracolumbar spine in March 2013; however, subsequent examinations reveal that the condition has resolved as noted by the VA examiners. Furthermore, the Veteran has not been prescribed bedrest by a treating physician for the condition. Therefore, a disability rating for incapacitating episodes due to IVDS is not warranted. Ankylosis In order to meet a compensable rating, under Note 5 of DC 5243, a favorable ankylosis of the entire spine must be present. If ankylosis is present, cervical and lumbar disabilities are rated as a single disability. The March 2016 VA examination was negative for the presence of ankyloses. The record does not indicate the manifestation of ankylosis of the Veteran's spine. Therefore, the lumbar disability is rated individually. Functional loss The Board considered factors cited in Deluca (pain, weakened movement, excess fatigability, or incoordination, functional loss due to pain and limited range of motion) in its decision. Under 38 C.F.R. Part 4, §4.40, functional loss of the musculoskeletal system may be considered if the individual exhibits the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Limitations due to pain, supported by adequate pathology, may be considered. The Board notes that the Veteran presented with limited range of motion in his back and functional loss due to pain in his March 2016 VA examination. The Veteran reported that he is unable to run at all, nor can he sit for long due to increased pain. The examiner described the functional loss as minimally limiting the Veteran's bending. Additionally, lifting was limited to 40 pounds occasionally and 20 pounds with repetitive movement. Here, the Board acknowledges that the Veteran does experience pain in his back, has missed work due to back pain, and has had some functional loss noted in his lower back. However, functional impairment, classified as minimally limiting his bending and lifting ability, does not approximate to a disability rating in excess of 20 percent. The Board will consider these factors in the extraschedular rating schedule below. Bilateral radiculopathy The Veteran was assigned a 20 percent disability rating for radiculopathy of his left lower extremity and 20 percent disability rating for radiculopathy of his right lower extremity, based in a December 2013 rating decision. The RO determined that the 20 percent rating was warranted based on a determination that the Veteran's bilateral radiculopathy showed moderate incomplete paralysis and assigned an effective date of July 2010. The Veteran sought additional consideration for his bilateral radiculopathy as he reported that he had radiculopathy with degenerative disc disease as a result of his service. The evidence does not include any findings that would support a finding that the radiculopathy of either extremity is greater in severity that moderate. In the March 2016 VA examination, the examiner found that the Veteran did not present with radicular pain or any other signs or symptoms due to radiculopathy. Since the Veteran does not present with paralysis of the sciatic nerve that is considered moderately severe, a rating in excess of 20 percent for bilateral radiculopathy is not warranted. Other associated objective neurological abnormalities, including bladder impairment The Veteran contends that he has a bladder disability as a result of his lumbar spine condition. See June 2016 VA Form 21-4318. The March 2016 VA examination is negative for any neurological abnormalities associated with the Veteran's thoracolumbar spine. The preponderance of the evidence weighs against a finding that the Veteran has a bladder disability associated with the service-connected disability. In this regard, the Board has fully considered the Veteran's lay testimony but the question of an association between any current bladder disability and the service-connected back disability is a complex medical question of causation that requires medical expertise to answer, and thus, the Veteran's lay testimony is insufficient on its own to provide this link. The medical evidence does not indicate such an associated disability. Additional conditions related to the lumbar spine After a full review of the record, the Board concludes that an increased rating in excess of 20 percent is not warranted for the Veteran's lumbosacral strain. The Board has considered his thoracolumbar region in relation to range of motion, IDVS, ankyloses, functional loss, bilateral radiculopathy, and considered the manifestation of his cervical spine disability. Additionally, the Board also recognizes that the Veteran has indicated that because of his lumbar spine disability, he suffers from sleep deprivation, memory loss, cognitive impairment, mood disorders, obesity, and blood pressure elevation. The Board may not make medical determination without relying on independent medical evidence. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Again, these matters are not before the Board and the Veteran is encouraged to file any claims for secondary service connection, under C.F.R. §3.310. Sarcoma of the left medial arm The General Rating Formula for muscle injuries provides the following, in pertinent part: under the miscellaneous section, a 100 percent rating is assigned for sarcoma of the soft tissue (of muscle, fat, and fibrous connective tissue). The corresponding note states that a rating of 100 percent shall continue beyond the cessation of any surgery, radiation treatment, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of §3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residual impairment of function. The General Rating Formula for skin provides the following, in pertinent part: pursuant to DC 7806, dermatitis or eczema is rated either under the specific criteria provided in DC 7806 or as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. See 38 C.F.R. § 4.118. Under DC 7806, a 10 percent disability rating is warranted for dermatitis or eczema with at least 5 percent but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. See Id., DC 7806. A 30 percent disability rating is warranted for dermatitis or eczema with 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12 month period. Id. A maximum schedular 60 percent disability rating is warranted for more than 40 percent of the entire body, or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Id. In August 2014, the Veteran stated that he experienced progressive pain, stiffness, soreness, and loss of flexibility in the left arm and around the sarcoma surgery scar. The Veteran also stated that he had loss of skin tissue and blood flow, as well as muscle loss, which caused paresthesia in the left arm at night. In June 2016, the Veteran stated that he experiences pain and stiffness with sharp stinging pain in his left arm with loss of muscle mass, skin tissue, and blood flow. He asserts that because of these symptoms, his arm falls asleep limits his functional ability, and he experiences a lack of mobility in his arm. See June 2016 VA-4138. In terms of medical evidence, the Veteran was afforded a VA examination for his sarcoma and associated skin conditions in March 2016. The examiner provided disability benefits questionnaires for skin diseases, scars, and muscle injuries. He diagnosed the Veteran with radiation dermatitis secondary to the removal of his sarcoma. He noted a mass was noted on the Veteran's exit exam, later diagnosed as a high grade spindle cell sarcoma, which was treated first with radiation, and then with excision. Since the procedure, the Veteran has not had a recurrence of the condition. It was noted that he did report a residual burning sensation in the area. Dermatitis was noted at less than 5 percent of the total body area with no presence on the hands, face, or neck. The dermatitis appeared slightly dry surrounding the surgical scar on the left anteromedial upper arm. Positive residuals were noted as a wide excision sarcoma on the left arm with skin graft donor present on the right thigh. The examination was negative for debilitating or non-debilitating episodes in past 12 months due to urticarial, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrloysis and also noted that there was no pain or instability present due to the dermatitis. The examiner opined that radiation dermatitis was common after external beam radiation, which often manifests as a residual burning sensation. He added that the Veteran had a minimal scar on his left arm and experienced no functional loss from his skin condition. After a full review of the record the Board concludes that the Veteran is not entitled to a compensable rating for his sarcoma and associated skin condition of the left medial arm. The Board notes that the Veteran underwent excision of his sarcoma in 2005. He has not received any treatment for sarcoma in the last 12 months and has had no recurrence or metastasis of the condition. Under DC 5329 note 1, an appropriate disability rating is assigned after sarcoma treatment. The RO determined that DC 7806 most resembles the Veteran's current condition. A residual scar from the procedure is present on the Veteran's left arm. The scar does not produce disfigurement of the head, face, or neck, does not limit functioning, and is not painful or unstable. In order for the Veteran to receive a compensable rating, his dermatitis must cover at least 5 percent of his body or require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Here, the scar is noted as 8 by nine centimeters and localized to his left arm and does not require systemic therapy. Furthermore, the examiner noted that there is no pain or instability associated with the scar. Based on these findings, a compensable rating for sarcoma and associated skin condition is not warranted. II. Extraschedular Consideration The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, 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. See 38 C.F.R. § 3.321 (b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). According to Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extra-schedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's low back and skin condition with the established criteria found in the Rating Schedule for these disabilities shows that the rating criteria reasonably describes his disability level and symptomatology, as discussed above. The Rating Schedule specifically contemplates pain, limitation of motion, and incapacitating episodes resulting from the Veteran's lumbar spine condition. The Rating Schedule specifically contemplates local recurrence or metastasis of the sarcoma conditions and ulceration, exfoliation, and systemic or nervous manifestations of the skin for dermatitis. There is no indication that his conditions result in any symptoms that fall so far outside the purview of the Rating Schedule as to render it inadequate. The Veteran's contentions that he has conditions that have developed as a result of his back and skin conditions may potentially be sought as secondary service connections claims; however, the extraschedular consideration is not warranted. III. Duties to Notify and Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2016). Here, the Veteran was provided with the relevant notice and information in a letter dated June 2009. He has received additional notice letters as his claim has developed. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He has not alleged any notice deficiency during the adjudication of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service records, VA records, and identified private treatment records have been obtained and associated with the claims file. The Veteran was also provided with VA examinations for his claimed lumbar spine and skin condition which, collectively, contain a description of the history of the disability at issue; document and consider the relevant medical facts and principles; and provide opinions regarding the etiology of the Veteran's claimed condition. The Board finds that these examinations, in aggregate, are sufficient to evaluate the current severity of the two increased claims in appellate status. ORDER Entitlement to a rating in excess of 20 percent for bilateral spondylosis with spondylolisthesis and degenerative disc disease of the lumbar spine at L5-S1 is denied. Entitlement to a compensable rating for sarcoma and associated skin condition of the left medial arm is denied. ____________________________________________ Nathaniel J. Doan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs