Citation Nr: 1759961 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 11-01 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for right side temporomandibular joint syndrome (TMJ), including as secondary to service-connected major depressive disorder. 2. Entitlement to an initial rating in excess of 10 percent for degenerative disease at L1 with straightening of lumbar lordosis (lumbar spine disability). 3. Entitlement to a rating in excess of 10 percent for dermatosis (also claimed as dermatitis, keratosis pilaris, pruritis, seborrhea and lichen planus) (skin disability) from May 16, 2009 to October 21, 2015. 4. Entitlement to a compensable rating for a skin disability from October 22, 2015. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and spouse ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran served on active duty from December 1998 until May 2009. These matters are before the Board of Veterans' Appeals (Board) on appeal from December 2009 and September 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. In August 2012, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing. A copy of the hearing transcript is associated with the Veteran's record and has been reviewed. In November 2014 the Board remanded the matters for additional development. In an interim August 2017 rating decision the RO increased the rating for dermatosis to 10 percent effective May 16, 2009 and reduced it to 0% effective October 22, 2015. The issues of entitlement to service connection for right side TMJ, including as secondary to service-connected major depressive disorder and to a compensable rating for a skin disability from October 22, 2015 are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appeal period, the preponderance of the evidence is against finding that the Veteran's degenerative disease at L1 with straightening of lumbar lordosis is manifested by 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 of abnormal kyphosis. 2. Affording the Veteran all reasonable doubt, the Veteran's service-connected skin disability, for the period on appeal from May 16, 2009 to October 21, 2015, at worst, affected at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (Code) 5242 (2017). 2. For the rating period on appeal from May 16, 2009 to October 21, 2015, the criteria for a rating of 30 percent for a skin disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.7, 4.118, Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board has reviewed the Veteran's record and finds that there exist no deficiencies in VA's duties to notify and assist that would be prejudicial and require corrective action prior to a final Board determination. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Bryant v. Shinseki, 23 Vet. App. 488 (2010) (regarding the duties of a hearing officer); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (corrective action to cure a 38 C.F.R. § 3.159(b) notice deficiency); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (timing of notification). The Board also notes that, to the full extent possible, VA complied with all prior remand instruction requests, and there exist no deficiencies in VA's duties to notify and assist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order); but see D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required). Legal Criteria, Factual Background and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial rating stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant 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. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Lumbar Spine Disability The Veteran contends that his lumbar spine disability has increased in severity since the September 2009 VA examination and that an increased initial rating is warranted. His service-connected lumbar spine disability is currently rated 10 percent under 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), Code 5242 (degenerative arthritis of the spine). Under the General Rating Formula, 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, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or 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; a 20 percent 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. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R § 4.71a, Codes 5235 to 5242. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). Furthermore, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). On September 2009 VA examination, the Veteran reported that he was given a medical discharge from the service for back and neck problems. He stated that he had low back pain that began after a bad parachute jump when he landed hard on his buttocks. Any bending or lifting caused pain; he was prescribed epidural injections, pain killers and muscle relaxants along with anti-inflammatory medications. His pain level was 9/10 and would last a few days. He did not use a brace, cane or other assistive devices; and the low back pain had no effect on his ability to work. On physical examination, forward flexion of the lumbosacral spine was to 85 degrees with pain at the end; extension was to 38 degrees with no pain. Left lateral flexion was to 30 degrees with no pain, right lateral flexion was to 37 degrees with no pain, left lateral rotation was to 25 degrees with no pain, and right lateral rotation was to 20 degrees with pain at the end. Straight leg raising was negative bilaterally. Toe and heel walking was normal. Reflexes were 1-2/4 and equal bilaterally. Babinski was normal. There was no additional limitation following repetitive use. X-rays of the lumbosacral showed straightening of the normal lumbar lordosis. X-rays of the thoracic spine showed no definite acute bony abnormality. The impressions were normal thoracic spine and straightening of lumbar lordosis. June 2010 VA examination findings were consistent with findings on September 2009. That examination revealed mild tenderness to palpation of the paraspinous muscles of the lumbar spine. No muscle spasm was noted. There was straightening of the lumbar lordosis. The Veteran's gait was normal. The diagnosis was straightening of the normal lumbar lordosis. The examiner opined that straightening of the normal lumbar lordosis is more likely than not a normal finding for the Veteran and is less likely associated with mild tenderness to palpation without muscle spasm to the lumbar region. November 2010 x-rays of the lumbosacral spine showed borderline disc space narrowing of T12-L1 with normal sacral iliac joints and vertebral alignment. January 2011 MRI [magnetic resonance imaging] of the lumbar spine shows very early spondylosis in the mid and lower thoracic spine and multilevel early disc desiccation with slight loss of T2 signal. A March 2012 VA medical opinion report revealed the Veteran had spondylosis in the thoracolumbar spine. He had joint deformities attributable to his arthritis condition of the thoracolumbar spine. He had non-incapacitating pain of the back. He did not have an arthritis condition with incapacitating exacerbations. On October 2015 VA back conditions examination, the Veteran reported having no improvement in his low back pain over the past 5 years; he stated that he continues with chiropractic treatment, and uses pain medication. He reported having early morning low back pain, which he stretches out in the morning upon awakening. During the day his pain is rated 5/10. Sitting or lying down will bring on tightening which increases the pain to 9/10. He is unable to sleep through the night or sit for prolonged periods due to pain. On range of motion testing, he had forward flexion to 90 degrees, extension to 20 degrees, right and left lateral flexion each to 30 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 30 degrees. Range of motion did not contribute to a functional loss. There was no pain noted on examination. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. He was able to perform repetitive use testing with at least three repetitions, there was no additional loss of function or range of motion after the three repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups. Pain and incoordination significantly limited functional ability with flare-ups. No increase in limitation of motion was reported. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing was 5/5. There was no muscle atrophy. His reflex and sensory examinations were normal. He had a negative straight leg raising test, and there was no radicular pain or any other signs or symptoms due to radiculopathy. There were no other neurologic abnormalities or ankylosis of the spine. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. He did not use any assistive device. There was no functional impairment of an extremity due to the thoracolumbar spine, such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The diagnoses were degenerative arthritis of the spine and intervertebral disc syndrome. More specifically, degenerative disc disease of the thoracolumbar spine was diagnosed in 2011, and degenerative joint disease of the thoracolumbar spine was diagnosed in 2010. There was no functional impact from the Veteran's thoracolumbar spine on his ability to work. He stated he works at an Army combat search and rescue program as a civilian employee. On review, the evidence indicates that during the appeal period, the Veteran's lumbar spine disability manifested with pain and limitation of motion. The evidence, however, does not show 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 of abnormal kyphosis. At worst, forward flexion of the Veteran's thoracolumbar spine was 85 degrees during the September 2009 VA examination and 90 degrees during the October 2015 VA examination. There is also no evidence of doctor-prescribed bedrest on account of intervertebral disc syndrome, under Diagnostic Code 5243. Moreover, there are no associated objective neurologic abnormalities for which separate ratings might be assigned. Accordingly, a disability rating in excess of 10 percent for a lumbar spine disability at any point during the appeal period is not warranted. The Board also considered whether the functional loss due to pain could result in a higher schedular evaluation. While pain alone does not constitute functional loss, the United States Court of Appeals for Veterans Claims (Court) has clearly indicated that the Board must consider the effects of pain, particularly as to any adverse impact on the normal working movements of the body. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In this case, the Veteran has complained of lumbar spine pain. Nevertheless, even considering the effects of pain, there is nothing in the record that suggests the pain resulted in a functional loss akin to the criteria which would support a higher initial disability rating. Accordingly, a higher initial rating based upon pain would be inappropriate. In sum, the evidence does not show that a disability rating in excess of 10 percent for the Veteran's lumbar spine disability is warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Skin Disability The Veteran contends that a higher rating is warranted for his service-connected skin disability, currently rated 10 percent from May 16, 2009 to October 21, 2015 and 0% effective October 22, 2015 under Code 7806 (dermatitis or eczema). (Entitlement to a compensable rating from October 22, 2015 is addressed in the Remand section of this decision.). Under Code 7806, a 10 percent rating is assigned for dermatitis or eczema affecting 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, or; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema affecting at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A maximum 60 percent rating is assigned for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or; when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118, Code 7806. On September 2009 VA skin diseases examination, the Veteran reported that he developed a skin rash in 2005 with eruption over much of his body. The appearance of the rash was variable, with some dry and some "vesicles." He was prescribed oral steroid dosepak to help clear the rash, but the rash would come back a couple of weeks later. At the time of the examination he reported having several lesions on his hands and elbows. He had mild itching before the eruptions occur and the itching would last for 2 to 3 days. He treated the eruptions with a steroid cream and they would clear-up in 2 to 3 days. On physical examination he had several very, very small flat elevations on the hand and index finger bilaterally. The color was the same as surrounding tissue and they were less than 1/16 inch in diameter and were raised less than 1/32 of an inch. There was no erythema or tenderness present at that time. There was no evidence of scratching present. The impression was dermatosis, very mild. In a February 2012 statement by Dr. M.E.W, of VA Medical Center (VAMC) post deployment clinic, it was noted that the Veteran had been treated at the post deployment clinic for the last year for skin rash/dermatitis consistent with eczema and continued on topical therapy to date. Furthermore, he was treated with oral steroids last summer for a total of 7 weeks and had a dermatology consult on his condition. His prognosis was good, and he was stable on his present treatments. A May 2014 VA outpatient treatment report shows the Veteran had a dark brown 2mm macule on the lumbar midline. He had mild hyperpigmentation on the right forearm and waistline. The assessment was skin neoplasm of uncertain behavior, rash in remission. During a May 2014 VA dermatology consult the Veteran reported he had a flare 2 weeks prior that was essentially cleared at the time of the consult. Also in May 2014 the Veteran underwent a shave biopsy of 2mm macule on the lumbar back. The diagnosis was junctional dysplastic nevus with mild architectural and mild cytologic atypia with lichenoid inflammation. In a January 2015 letter, the Veteran's private physician, Dr. S.M.R., noted that she has treated the Veteran on an ongoing bases for a rash that was originally diagnosed during service. The dates of treatment for a reoccurring rash included November 2013, May 2014, June 2014 and November 2014. During flare-ups, the rash typically covers 5 percent to 10 percent of the affected areas that typically include his feet, lower legs, hands and fingers, ears, and arms. In other instances, the rash has covered approximately 25 percent of the arms, hands and fingers, lower legs, feet and abdomen. Additionally, the rash does infrequently occur to a lesser degree on his lips, head and neck, top of shoulders, waistline, and upper legs. Neither non-steroidal nor steroidal based topical creams provide relief of his symptoms, but oral corticosteroids have provided him temporary relief. Due to health concerns and cautions over taking the corticosteroids for such a long period of time, he has recently limited their use. The Board has focused particularly on the findings in the February 2012 statement by Dr. M.E.W that the Veteran had been treated for the last year for skin rash/dermatitis consistent with eczema and continued on topical therapy and was treated with oral steroids last summer for a total of 7 weeks. Additionally, the January 2015 letter by the Veteran's private physician noted the rash has covered approximately 25 percent of the arms, hands and fingers, lower legs, feet and abdomen. It was noted that neither non-steroidal nor steroidal based topical creams provided relief of his symptoms, but oral corticosteroids have provided him temporary relief. Due to health concerns and cautions over taking the corticosteroids for such a long period of time, he had recently limited their use. Thus, the Board has determined that the assigned 10 percent rating for the period from May 16, 2009 to October 21, 2015 is insufficient, and a higher rating of 30 percent is warranted for the stated period (May 16, 2009 to October 21, 2015). 38 C.F.R. § 4.118, Code 7806. The question of whether an even higher rating is warranted for the service-connected skin disability for the stated period has been considered. The Board finds that the Veteran's service-connected skin disability has not been manifested by 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, to warranted the next higher rating of 60 percent for the period from May 16, 2009 to October 21, 2015. For the same reasons, a higher rating is not warranted under any other applicable diagnostic code for rating the Veteran's skin disability. The rating for the period beginning October 21, 2015 is addressed in the REMAND section of this decision. Other Considerations A total disability rating based on individual unemployability is not inferred in this instance as it is found in the record that the Veteran works full-time in a military program as a civilian employee. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to an initial rating in excess of 10 percent for degenerative disease at L1 with straightening of lumbar lordosis is denied. A 30 percent rating for dermatosis (also claimed as dermatitis, keratosis pilaris, pruritis, seborrhea and lichen planus) from May 16, 2009 to October 21, 2015 is warranted, subject to regulations governing payment of monetary awards. REMAND The Veteran has a current diagnosis of TMJ specifically described as right side disc displacement without reduction, diagnosed in service in October 2008. VA examiner in October 2015 opined that the etiology of the Veteran's TMJ right side disc displacement is congenital in nature as his severe Class III occlusion does not afford him the ability to disclude his posterior teeth leading to stress on the TMJs. He had no history of mandibular trauma. The examiner further opined that it is not likely that the malocclusion was subject to injury or aggravated by service; it is a congenital condition (genetic), and he was not subjected to trauma. The disc displacement was found unsurprising due to his malocclusion. The Veteran's representative, in an October 2017 Appellant's Brief, noted that the VA examiner did not address whether the Veteran's TMJ was being caused by his service-connected mental health disorder. The representative suggested that the claim be granted or remanded for development to ascertain whether the Veteran's right sided TMJ is secondary to his service-connected major depressive disorder. Thus, an alternative theory of service connection has been raised by the Veteran, and a remand is necessary for the RO to readjudicate the claim, to include consideration of secondary service connection. This matter is therefore remanded for the examiner to provide an opinion on whether the Veteran's right sided TMJ is caused or aggravated by his service-connected major depressive disorder. A zero percent rating for the service-connected skin disability was resumed effective October 22, 2015. While the Veteran received a VA examination in October 2015, the examination was conducted during a period when his skin problems were in remission. The United States Court of Appeals for Veterans Claims (Court) has recognized that some conditions, by their inherent nature, wax and wane and accordingly are sometimes active and other times not. See Ardison v. Brown, 6 Vet. App. 405, 408 (1994). Here, the examiner explained that the Veteran's skin disability (lichen planus) is an autoimmune disorder which, though very common, is not well understood; and it is characterized by waxing and waning lesions and usually responds well to steroid therapy. In Ardison, the Court held that the Board may not rely on a medical examination performed during the inactive stage of a Veteran's fluctuating condition. Id. Thus, pursuant to the Court's holding in Ardison, an examination should be conducted during a period when there is a flare-up of his skin disability. See Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Any outstanding records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. The Veteran must be furnished a 38 C.F.R. § 3.159(b) notice letter addressing his claims, including the TMJ claim under 38 C.F.R. § 3.310 as secondary to a psychiatric disorder. He should be afforded the opportunity to submit any outstanding private treatment records pertinent to his TMJ and skin disabilities. He should be asked to provide any necessary authorization. All outstanding VA treatment records should be obtained. 2. Obtain an addendum opinion for the Veteran's right sided TMJ disc displacement by the same examiner who conducted the October 2015 compensation dental and oral examination. If the October 2015 VA examiner is unavailable then another qualified examiner should be requested to provide the same opinion. If deemed necessary by the examiner, afford the Veteran another VA TMJ conditions examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran's record (pertinent to this matter) must be made available and reviewed by the examiner. The examination report should note that the record was reviewed. The examiner is requested to review all pertinent records associated with the Veteran's record and offer comments and an opinion addressing whether it is at least as likely as not (i.e., probability of 50 percent) that right sided TMJ disc displacement is proximately due to or aggravated (beyond a natural progression) by the Veteran's service-connected major depressive disorder. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved is required. 3. Additionally, schedule a VA dermatology examination concerning the Veteran's service-connected skin disability. This examination should, to the extent possible, be conducted during a period when the Veteran's skin problems are flaring up. The AOJ should take appropriate steps to coordinate with the Veteran in conducting the examination during such a period to determine the extent and severity of his skin disability. The examination should include all necessary diagnostic testing or evaluation. The Veteran's record, including a complete copy of this remand, must be made available for review. The examiner is requested to examine the Veteran's entire body and to describe the manifestations of the service-connected skin disability, in terms of the percent of the total body area and percent of exposed areas affected by lesions. The examiner should also document the treatment given for the skin disability, including the duration of use of any systemic therapy such as corticosteroids or other immunosuppressive drugs. 4. After all of the above actions have been completed and the Veteran has been given adequate time to respond, readjudicate his claims. If a claim remains denied, issue to the Veteran and his representative a supplemental statement of the case, and afford opportunity to respond. Thereafter, the case should be returned to the Board, for further appellate action. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs