Citation Nr: 1734227 Decision Date: 08/21/17 Archive Date: 08/30/17 DOCKET NO. 10-31 358 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for peripheral neuropathy. 2. Entitlement to service connection for hypertension, to include as due to treatment for service-connected acne. 3. Entitlement to service connection for residuals of a subdural hematoma, claimed as a brain aneurysm, to include as secondary to posttraumatic stress disorder (PTSD). 4. Entitlement to an increased rating in excess of 50 percent for PTSD. 5. Entitlement to an increased rating in excess of 10 percent for a skin disorder, originally granted as acne related to Agent Orange exposure. 6. Whether the reduction from 100 percent to 20 percent for prostate cancer, effective March 1, 2013, was proper. 7. Entitlement to an increased rating in excess of 20 percent for residuals of prostate cancer from March 1, 2013. 8. Whether the discontinuance of entitlement to special monthly compensation (SMC) at the housebound rate was proper. 9. Entitlement to total disability based on individual unemployability (TDIU). 10. Entitlement to SMC for loss of use of a creative organ. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1969 to March 1971. His service included service in the Republic of Vietnam. Additionally, he earned a Bronze Star Medal with "V" device for his Vietnam service. The Veteran had additional Army National Guard service. These claims come before the Board of Veterans' Appeals (Board) on appeal from June 2009 (skin), May 2013 (hypertension, PTSD, brain aneurysm), December 2014 (prostate and SMC), and March 2016 (peripheral neuropathy) rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). Several of these issues were previously before the Board in July 2014. The Board remanded the issues for issuance of a Statement of the Case and for the Veteran to be afforded additional examinations related to his skin claim. The Board also referred the issue of entitlement to a TDIU. In a May 2015 rating decision the RO denied entitlement to a TDIU. Although the Veteran did not provide a timely notice of disagreement with this rating decision, in June 2015 he submitted a VA Form 21-4192 Request for Employment information. The Board therefore will consider TDIU to remain on appeal as stemming from his increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes that the Veteran's attorney has argued that all claims need to be remanded because VA has not met their duty to assist by obtaining the Veteran's service treatment records. This argument is based on an NPRC response was that all of the Veteran's available records had been provided to VA previously. The attorney interpreted this to mean the Veteran's service treatment records from his service from 1969 to 1971 were provided to the RO at some point. However, the records that were obtained were related to his Army National Guard service. His service treatment records from 1969 to 1971 remain missing, and are presumed destroyed. This will be additionally addressed below. The Board will not remand for additional fruitless attempts to obtain missing service treatment records. The claim of entitlement to service connection for peripheral neuropathy was initially denied in a February 1998 rating decision. Although the Veteran did not appeal this decision and it became final, in 2015 (based upon the date entered into VBMS, as there is no date-stamp on the records) the RO obtained Army National Guard service treatment records. The February 1998 rating decision did not indicate that these 1974 and 1975 records were before it at the time of that decision. These records constitute service record evidence that could have been previously obtained and requires VA to reconsider the claim, instead of treating the claim as one to reopen. See 38 C.F.R. § 3.156(c)(2016). The issue(s) of entitlement to service connection for hypertension, increased ratings for PTSD and skin disorder, whether discontinuance of SMC was proper, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has not been diagnosed with peripheral neuropathy of the upper or lower extremities. 2. The competent evidence of record does not support that the Veteran suffered a subdural hematoma as a result of his service or his service-connected PTSD. Medical records do not include a diagnosis of a brain aneurysm. 3. In a May 2013 rating decision, the Veteran was granted service connection for prostate cancer and assigned a 100 percent evaluation effective April 4, 2013. 4. In September 2014, the RO notified the Veteran of a proposed rating decision to reduce the evaluation for his prostate cancer from 100 percent to 0 percent; the RO promulgated the proposed reduction in a December 2014 rating decision, effective March 1, 2015. 5. The RO's decision to reduce the evaluation for prostate cancer from 100 percent disabling to a noncompensable rating was supported by the evidence of record at the time of the reduction, and was made in compliance with applicable due process laws. The Veteran's rating beginning March 1, 2015 has been increased to 20 percent based on a 2016 VA examination that was not before the RO at the time of the initial noncompensable reduction. 6. At the time of the December 2014 decision, which reduced the rating for prostate cancer, the evidence did not show urinary frequency, urinary voiding dysfunction, obstructed voiding, urinary tract infection or renal dysfunction. The Veteran had not received any additional surgical, X-ray, antineoplastic chemotherapy, or any other therapeutic procedure for prostate cancer; there was no local reoccurrence or metastasis of the prostate cancer. 7. From March 1, 2015, the Veteran's residuals of prostate cancer resulted in daytime voiding interval between one and two hours and awakening to void two times per night. His residuals did not require the wearing of absorbent materials or result in renal dysfunction. 8. The Veteran has erectile dysfunction associated with his service-connected prostate cancer. There is no evidence of penile deformity. CONCLUSIONS OF LAW 1. Service connection for peripheral neuropathy is not warranted. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2016). 2. Service connection for residuals a subdural hematoma is not warranted. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2016). 3. The reduction of the rating for prostate cancer from 100 to noncompensable, effective March 1, 2015, was proper. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.105 (e), 4.115b, Diagnostic Code 7528 (2016). 4. From March 1, 2015, the criteria for a rating in excess of 20 percent for residuals of prostate cancer, rated as urinary frequency, have not been met. 38 U.S.C.A. §§ 1155; 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.105 (e), 3.159, 4.1-4.14, 4.21, 4.115a, 4.115b, Diagnostic Code 7528 (2016). 5. The criteria for SMC for loss of use of a creative organ are met since April 16, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.350 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letters provided in August 2008, April 2009, September 2012, April 2013, February 2014, September 2014, and December 2014. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's private and VA treatment records have been obtained. Additionally, his Social Security Administration (SSA) records have been obtained. The Veteran's service treatment records for his period of active service from 1969 to 1971 are not on file and were presumably destroyed in a fire at the NPRC in St. Louis, Missouri, in 1973. The United States Court of Appeals for Veteran's Claims (Court) has held that in cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The claims file does contain limited treatment records (enlistment and reenlistment examinations and medical histories) from the Veteran's Army National Guard service from 1974 and 1975. Additionally, multiple VA examinations have been conducted. The Veteran had two VA examinations to determine the severity of his prostate cancer residuals. The examination reports included interview of the Veteran where he supplied the responses regarding his voiding dysfunction, urinary frequency, and erectile dysfunction, among other pertinent information. He was afforded a VA examination to address his aneurysm claim in May 2013. The RO requested a medical opinion regarding the Veteran's claim that he had a brain aneurysm secondary to his PTSD. The medical opinion included a review of the record and was supported by an explanation of the cause of subdural hematomas. Regarding the Veteran's claims of cognitive dysfunction, the Board is remanding his claim for an increased rating for PTSD to address whether these symptoms stem fully or partially from his service-connected mental health condition. The Veteran's attorney as alleged that the Veteran's skin examinations are inadequate. The Board agrees and his skin disorder claim is being remanded for additional evaluation. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309 (a) is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303 (b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain diseases, to include organic diseases of the nervous system, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. In this case, as reviewed below, the evidence of record does not reflect that the Veteran had either peripheral neuropathy or another organic disease of the nervous system, to a compensable degree, within one year of discharge from active duty; hence, this presumption does not apply. Service connection may be granted for any disease that is initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (adding that "[w]hen service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition"). Additionally, service connection may be established by the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Determinations regarding service connection are based on a review of all of the evidence of record, including pertinent medical and lay evidence. 38 U.S.C.A. § 1154 (a); 38 C.F.R. § 3.303 (a). Under certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303 (b). To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) ("A veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' to prevail."). Peripheral Neuropathy As noted in the introduction, the Veteran was initially denied service connection for peripheral neuropathy in 1998. The February 1998 rating decision denied service connection because the Veteran did not have a current diagnosis of peripheral neuropathy and because the evidence did not show that he developed peripheral neuropathy within one year of exposure to Agent Orange with resolution after two years. This refers to the Agent Orange presumptive for service connection for peripheral neuropathy. Diseases associated with exposure to certain herbicide agents currently include "early-onset peripheral neuropathy." See 38 C.F.R. § 3.309(e)(2016). The Veteran is presumed to have been exposed to Agent Orange ("certain herbicide agents") due to his Vietnam service. In prior versions of 3.309(e) the term was "acute and subacute peripheral neuropathy. Also in prior versions, Note 2 included that "the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of onset." The current 2016 version of 38 C.F.R. § 3.309(e) no longer has a Note which addresses peripheral neuropathy. Although there is a change in 3.309 from "acute and subacute peripheral neuropathy" to "early-onset peripheral neuropathy," with a corresponding change of the earlier Note 2 being removed, this change does not impact the outcome in this case. Presumptive service connection for peripheral neuropathy cannot be granted in this decision because there is no diagnosis of peripheral neuropathy. The Board has considered the impact of the Veteran's missing service treatment records on this decision. However, the Board notes that service connection requires a "current disability." Although VA interprets "current" to include any disability that was present during the period on appeal, in this case, there is no indication that the Veteran has ever been diagnosed with peripheral neuropathy. Indeed, in reviewing the record, the Board was unable to find a statement from the Veteran which described the onset of symptoms that he believed met a diagnosis of peripheral neuropathy. The earliest medical examination in the record is from the Veteran's enlistment in the Army National Guard. The February 1974 medical examination was negative, and the Veteran provided a medical history that was negative for neuritis. On the portion where the Veteran could report any medical history (as opposed to the checklist provided) the Veteran did not report any abnormalities. The October 1975 reenlistment examination and reported medical history form the Veteran were equally negative for notations related to peripheral neuropathy. The earliest VA examination in the record is from December 1988; again, peripheral neuropathy was not diagnosed and the Veteran did not report symptoms of peripheral neuropathy of the upper or lower extremities. Indeed, a review of the entire record contained in VBMS does not reveal a diagnosis of peripheral neuropathy of the upper or lower extremities. A November 2006 VA treatment record diagnosed cervical radiculitis. A February 2007 VA treatment record diagnosed cervical radicular pain due to foraminal stenosis at C3-4 and C4-5. The Veteran saw a VA neurologist in December 2007 who diagnosed left C4-5 disk herniation and possibly left C5 radiculopathy as well as radiculopathy of L4. "No focal neurologic deficit except for absent reflexes bilaterally of the lower extremities." In June 2009, a MRI showed at least two levels of foraminal narrowing that corresponded to the Veteran's area of pain in his neck. He was assessed with neuralgia of the upper extremities. Peripheral neuropathy was not diagnosed during any of these assessments. In April 2012, the Veteran was treated by the University Medical Center and subsequently the Jackson VAMC for a subdural hematoma. Medical care and physical therapy consultations did not include a diagnosis of peripheral neuropathy. In June 2017, the Veteran's attorney provided an internet article which noted that peripheral neuropathy is a "relatively common side-effect of cancer." "Anyone diagnosed with cancer is at risk for this condition." The article noted that the risk of peripheral neuropathy increases based on tumor location and treatment with chemotherapy. The Veteran was diagnosed with prostate cancer and underwent a radical prostatectomy in April 2013. He did not undergo chemotherapy. He has been afforded two VA examinations to assess the functional impact of his prostate cancer and the treatment for his prostate cancer. During the 2014 and 2016 VA examinations the Veteran did not complain of symptoms of peripheral neuropathy subsequent to his cancer diagnosis, and peripheral neuropathy was not diagnosed. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The evidence of record does not show that the Veteran has ever been diagnosed with peripheral neuropathy. The Board notes that the Veteran is not service connected for his cervical or lumbar spine disabilities, so the associated radicular symptoms of his spine disabilities do not fall under the umbrella of the Board's consideration for service connection. Accordingly, the claim for service connection for peripheral neuropathy is denied. There is no doubt to resolve. See 38 U.S.C.A. § 5107 (b); Gilbert supra, 55-57 (1991). Subdural Hematoma In November 2012, the Veteran filed a claim for service connection for a brain aneurysm. He noted that he "had a vein in his brain with possible aneurysm with memory loss secondary to PTSD." SSA records include that he was granted SSDI due to organic mental disorders and essential hypertension. He reported he first had a seizure in May 2012 with no further seizures after brain surgery at the "University Hospital." This paperwork was filled out by his wife. A similar form, filled out by an SSA examiner, noted the Veteran had his first seizure in 1995 and that he had last had a seizure prior to his "brain operation" for a "leaking vein." The examiner filling out the form noted the Veteran had a "fuzzy memory" and that University Medical Center records showed he went to the emergency room in April 2012 after passing out. Medical records in the claims file do not include treatment for a seizure in 1995, or other statements from the Veteran that he had seizures prior to 2011. The examiner who filled out the above-mentioned form also provided a psychological report in January 2013. Veteran was accompanied by his wife, with whom he had been married for 37 years. The examiner cited VAMC records where his "allegations refer to cognitive difficulties." He complained of memory loss, agitation and confusion, and problems with balance. He was diagnosed with chronic left frontal subdural hematoma. During the January 2013 psychological evaluation, he reported a medical history of a stroke in April 2012 and two surgeries at University Medical Center, one in April and one in May 2012. He was being treated at the VAMC for memory loss. His wife stated that he had "fallen and injured his head" in November 2011 but did not tell anyone until after he had a "stroke." His major functional limitation was "concentration. I had a stroke and I also have a knee problem, but concentration and memory are the main thing." The examiner diagnosed cognitive disorder NOS, with features of PTSD. SSA records included a February 2013 medical report by Dr. L.Z., where the Veteran reported a head injury in November 2011 due to a motor vehicle accident. He had brain surgery in 2012 secondary to "a vein leaking over his brain from a stroke." His current symptoms include memory loss, forgetfulness, and confusion. He also had a history of seizure related to "this." The SSA records contain the University Medical Center records regarding the Veteran's subdural hematoma. In April 2012, the Veteran was brought to the emergency room after he "passed out." He reported his symptoms began approximately 2 months prior and had never occurred before. Additional symptoms included sweating, then frontal headache and syncope and confusion. He reported he was in a motor vehicle accident and hit his head against the steering wheel. His symptoms began after that. He did not seek treatment after the accident. He had a medical history of hypertension and PTSD. The Veteran left against medical advice despite being told he may die. He was encouraged to return as soon as possible. Another record noted that the Veteran had a large collection of blood in his brain which could quickly cause permanent brain damage and death if not fixed. He was assessed with a subdural hematoma with brief loss of consciousness. An occupational therapy note indicated the Veteran had difficulty with his balance in walking and decreased use of his right hand in coordination and strength tasks. He had cognitive deficits and was easily confused. He had difficulty comprehending what was said to him and retaining the information. The following day he underwent emergent left frontal subdural hematoma bur hole evacuation. The history included that he was "seen after trauma to the head in late November after which he was doing ok, but progressively became more and more confused." On CT there was "left frontal subdural hematoma with the largest width of 2 cm causing mass effect on the brain and some macro hemorrhages along the dural surface. Bur holes were indicated to evacuate a chronic liquified subdural hematoma and allow the patient to improve." In May 2012, at the University Hospital, the Veteran underwent a left craniotomy for subdural hematoma evacuation. The operation was performed because his wife indicated that following his April 2012 surgery he did not return to normal. In May 2013, the Veteran was provided a VA examination with an opinion regarding his aneurysm claim. The Veteran was noted to have a diagnosis of subdural hematoma from April 2012. The medical history was described as a "large left subdural hematoma found in April 2012 that was drained at University Medical Center." He was seen in April 2012 with confusion, slurred speech and passing out and a CT showed a "large left frontal chronic subdural hematoma with a little fresh bleeding, midline shift and some frontal edema. There was also significant cortical and cerebellar atrophy present." The examiner noted that there was no record for a cerebral aneurysm. The Veteran was on medication for seizures prophylactically, but had no additional seizures after his emergency room presentation with confusion. The Veteran reported his history as having had a "CT scan for acting strange and blacking out in 2012 and they found an aneurysm." During the interview, the Veteran had poor short-term memory. On neurological evaluation, the Veteran's speech and gait were normal. His muscle strength was normal throughout. His deep tendon reflexes were normal throughout. He had no muscle weakness. The examiner noted the Veteran also had a mental health disorder. Regarding the relationship between the Veteran's subdural hematoma and his service-connected PTSD, the examiner provided a negative nexus opinion. In explanation, the examiner noted that a subdural hematoma was "bleeding into the potential space between the cortical surface of the brain and the inner table of the skull. It typically occurred related to trauma of small bridging veins between the cortical surface and the saggital sinus they empty into. This commonly occurs in elderly individuals with minimal trauma due to atrophy of the brain and stretching these fragile veins across the space. SDH may also occur in individuals on anticoagulation." The examiner found that the Veteran had brain atrophy, putting him at risk for a subdural hematoma. "There is no medical association between brain atrophy and PTSD. It is therefore unlikely that his PTSD is related to his SDH." In December 2016, the Veteran's attorney provided a copy of a medical abstract (internet print-out). The abstract was titled "Brain integrity and cerebral atrophy in Vietnam combat veterans with and without PTSD." The description noted that "PTSD is associated with decreased hippocampal volume, but the relationship between trauma and brain morphology in the absence of PTSD is less clear." The study was based on six patients with PTSD and five controls. The abstract admitted that the "small sample size limited the power to detect between -group differences. Both groups showed heterogeneity in cerebral atrophy." The only statistically significant finding was of volume difference in multivariate white matter of the right temporal lobe (superior temporal gyrus, fusiform gyrus, parahippocampal gyrus, white-matter stem, middle temporal gyrus, and inferior temporal gyrus). Given that brain atrophy was heterogenous between the PTSD group and the control group, this supports the 2013 examiner's statement that atrophy occurs due to age. Additionally, the article indicated that the only statistically significant finding in the small sample size was of volume in the white matter of the right temporal lobe; however, the Veteran's subdural hematoma was on his left side. The Board recognizes that the Veteran believes that his PTSD resulted in his subdural hematoma; however, the medical evidence does not support this contention. The Veteran's PTSD (to include chronic sleep impairment and medications) and his subdural hematoma both have an impact on his memory, but the 2013 medical opinion noted that PTSD is not causally related to a subdural hematoma. The medical records from University Medical Center and SSA indicated that the Veteran's April 2012 "passing out" and seizures began following a November 2011 motor vehicle accident. Regarding the impact of the Veteran's PTSD on his memory and cognitive function; the Board is remanding his increased rating claim for PTSD (symptoms included memory complaints prior to his diagnosed subdural hematoma) for an evaluation and opinion. The competent and credible evidence of record shows that the Veteran suffered a subdural hematoma in 2011 (40 years after discharge from service), that the subdural hematoma occurred after a motor vehicle accident, and the medical opinion of record is that his subdural hematoma was not related to his service-connected PTSD. The Board notes that the Veteran's service treatment records are not of record, but the Veteran has never indicated that he suffered a head injury in service. Given the urgency of having bur holes to release the bleed on his brain in 2012 it is likely that his subdural hematoma was a recent occurrence in 2012. As there is no competent evidence linking his subdural hematoma to service or a service-connected disability, entitlement to service connection is not warranted. There is no doubt to resolve. See 38 U.S.C.A. § 5107 (b); Gilbert supra, 55-57 (1991). Reduction A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C.A. § 1155 and Greyzck v. West, 12 Vet. App. 288, 292 (1999). Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons, and the RO must notify the veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. The veteran is also to be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105 (e). VA's General Counsel has held that the provisions of 38 C.F.R. § 3.105 (e) do not apply where there is no reduction in the amount of compensation payable. VAOPGCPREC 71-91; VAOPGCPREC 29- 97. It reasoned that this regulation is only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable. In the present case, the RO proposed reducing the rating for prostate cancer from 100 percent disabling to noncompensable in a September 2014 rating decision, with notice also sent in September 2014. The Veteran did not request a hearing. The reduction was finalized in a rating decision issued in December 2014, with an effective of March 1, 2015. Thus, the Board finds that the provisions of 38 C.F.R. § 3.105 (e) are applicable and were met. The Board must, however, still consider whether the reduction was factually appropriate based upon the evidence of record. Rating agencies will handle cases affected by change of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. VA benefits recipients may be afforded greater protections under 38 C.F.R. § 3.344 (a) and (b), which sets forth the criteria for reduction of ratings in effect for five years or more, which stipulate that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction and prohibit a reduction on the basis of a single examination. Brown v. Brown, 5 Vet. App. 413, 417-18 (1995). However, with respect to other disabilities that are likely to improve (i.e., those in effect for less than five years), re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344 (c). Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421; 38 C.F.R. § 3.344 (c). In a May 2013 rating decision, prostate cancer was granted with an initial 100 percent rating, effective April 4, 2013. The 100 percent rating was provided under Diagnostic Code 7528. The May 2013 rating decision noted that an evaluation of 100 percent was assigned during active malignancy or antineoplastic therapy and that six months following completion of treatment the residual disability would be rating based on the findings of a VA examination. The rating decision noted that there was a likelihood of improvement and the assigned 100 percent evaluation was not considered permanent and it would be subject to future review examination. The Board notes that the Veteran was given a review examination in August 2014 and the proposed rating was issued in September 2014. As the 100 percent rating for prostate cancer had been in effect for less than 5 years, the provisions of 38 C.F.R. § 3.344 (a) and 38 C.F.R. § 3.344 (b) are not applicable. Instead, the provisions of 38 C.F.R. § 3.344 (c) apply. Finally, in determining whether a reduction was proper, the Board must focus upon evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition had actually improved. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282 (1992). It should be emphasized, however, that such after-the-fact evidence may not be used to justify an improper reduction. In the present case, the Board finds that the reduction of the Veteran's disability ratings from 100 percent to noncompensable for his service-connected prostate cancer was proper. The Board notes that the noncompensable rating was changed to 20 percent in a January 2016 rating decision, following a January 2016 examination based on the Veteran's claim for an increased rating received in September 2014. The 20 percent rating was assigned from March 1, 2015. However, the Board must review if the initial reduction was proper, and that reduction was to a noncompensable rating. As previously noted, service connection was originally awarded for prostate cancer under Diagnostic Code (DC) 7528. Under DC 7528, a 100 percent rating may be assigned for malignant neoplasms of the genitourinary system. The Note attached to DC 7528 states that following cessation of surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure, the 100 percent rating shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105 (e) of this chapter. If there has been no local reoccurrence or metastasis, the disorder should be rated based on the residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115 (b) 4.115b, Diagnostic Code 7528. The Veteran was not afforded a VA examination prior to the May 2013 rating decision which provided the 100 percent rating. The 100 percent rating was based on the Veteran's report of a diagnosis of prostate cancer with a radical prostatectomy, which was confirmed through treatment records. VA treatment records noted the Veteran underwent the radical prostatectomy on April 16, 2013. A May 2013 VA treatment note (legacy content) noted that the Veteran had recent prostate surgery where they "removed all of the cancer." He was then-currently wearing a diaper, but he was unsure if this was a permanent arrangement. Notably, six months from April 16, 2013, the date of the Veteran's prostate surgery, would have been September 2013. However, the Veteran's residuals examination was not provided until August 2014. The August 2014 review VA examination included that the Veteran underwent a radical retropubic prostatectomy with bilateral pelvic lymph node dissection in April 2013 after being formally diagnosed with prostate cancer in February 2013. His last GU note from May 2013 noted the Veteran discussed adjuvant radiation, but the plan was for PSA monitoring. His last PSA in February 2014 was 0.01 ng/ml. The Veteran voiced no complaints of pain or trouble voiding. He was staying busy with household chores and mowing the lawn without problems. The status of his prostate cancer was "remission" following radical prostatectomy in April 2013. He did not report voiding dysfunction, recurrent urinary tract or kidney infections, erectile dysfunction, retrograde ejaculation, or other residual conditions/complications. He did not have renal dysfunction due to his prostate cancer. He had a scar related to his surgery, but it was not painful or unstable or greater than 39 sq. cm. His prostate cancer did not impact his ability to work. The examiner noted that identifying any increased limitations during a flare up would require mere speculation. The examination report did not include that the Veteran had indicated he had any flare-ups, as his cancer was considered to be in remission. Following the August 2014 examination, the RO proposed to reduce the Veteran's prostate cancer rating from 100 percent to noncompensable in a September 2014 rating decision. In a September 2014 statement, the Veteran requested an increased rating for prostate cancer. A December 2014 rating decision implemented the proposed reduction to noncompensable for prostate cancer, effective March 1, 2015. In January 2016, the Veteran was again afforded a VA prostate examination. He was diagnosed with adenocarcinoma of the prostate in 2013. He had a radical prostatectomy on April 16, 2013 at Jackson VA hospital. He had complete erectile dysfunction since the surgery. Viagra did not work for him. And he was unable to achieve an erection sufficient for penetration and ejaculation. He did not have retrograde ejaculation. The disease was noted to be in remission. The Veteran had completed treatment for prostate cancer, with his treatment consisting of the radical prostatectomy. He had voiding dysfunction with urine leakage that did not require the wearing of absorbent material. His voiding dysfunction did not require the use of an appliance. His voiding dysfunction caused increased urinary frequency with daytime voiding interval between one and two hours. His nighttime awakening to void was two times. His voiding dysfunction did not cause signs or symptoms of obstructed voiding. He did not have a history of recurrent symptomatic urinary tract or kidney infections. He had no other residual conditions or complications due to his prostate cancer and treatment. He had no renal dysfunction. The Veteran's scar from prostate surgery was not painful or unstable and did not have a total area greater than 39 sq. cm. His PAS on August 19, 2015 was 0.01. His prostate cancer did not impact his ability to work. Following the January 2016 examination, the RO issued a rating decision which changed the Veteran's rating for his prostate cancer from noncompensable to 20 percent, effective March 1, 2015. Thus, although the original reduction was to a noncompensable rating, this rating decision changed the Veteran's staged ratings to 100 percent from April 4, 2013 to February 28, 2015, and 20 percent from March 1, 2015. The 20 percent rating was provided based on the Veteran's residual that he had a daytime voiding interval between one and two hours. On an August 2016 notice of disagreement, the Veteran's attorney noted that he wanted a rating in excess of 20 percent for his prostate cancer and an earlier effective date than March 1, 2015. The Board notes that the Veteran's 100 percent rating was in effect prior to March 1, 2015, so the request for an earlier effective date would not provide the Veteran with an increase in disability rating, and in fact, could only result in the same or a lower rating. The Board therefore assumes that the request for an earlier effective date than March 1, 2015 for the 20 percent rating must be a mistake. In this case, the reduction of the 100 percent schedular rating to noncompensable for prostate cancer was proper. Pursuant to Diagnostic Code 7528, the Veteran was afforded a comprehensive VA examination in 2014 that revealed that his prostate cancer was in remission and had not been treated since 2013. The original reduction to a noncompensable rating based on a 2014 examination where the Veteran denied any genitourinary residuals related to voiding or renal dysfunctions at the time of that examination. Given the evidence of record at the time of the December 2014 rating decision, particularly the Veteran's responses to the 2014 VA examination wherein he denied residuals, the reduction to noncompensable was proper. The Board notes that the rating was increased to 20 percent in a subsequent rating decision following a 2016 examination which included the Veteran's complaint of urinary frequency. Obviously, the information the Veteran provided during the 2016 examination was not available to the RO at the time of the original reduction to a noncompensable rating. The subsequent 20 percent rating was assigned from the effective date of the reduction (March 1, 2015) based on the Veteran's September 2014 claim for an increased rating. In sum, the reduction of the Veteran's disability rating for prostate cancer from 100 to noncompensable was proper. The Board has considered the applicability of the benefit of the doubt rule. As the preponderance of the evidence shows the reduction was proper, the claim is denied. See 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. See generally, 38 C.F.R. § 4.1. Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different rating for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Diagnostic Code 7528 directs that if there has been no local recurrence or metastasis, then the cancer is rated based on residuals as voiding dysfunction or renal dysfunction, whichever is the predominant disability. 38 C.F.R. § 4.115b. As such, the Veteran's residuals of prostate cancer have been rated under 38 C.F.R. § 4.115a for voiding dysfunction based on his description of residuals. Voiding dysfunction is rated based on urine leakage, frequency, or obstructed voiding. Urinary leakage involves ratings ranging from 20 to 60 percent and contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials, which must be changed less than 2 times per day. When there is leakage requiring the wearing of absorbent materials, which must be changed 2 to 4 times per day, a 40 percent disability rating is warranted. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day, a 60 percent evaluation is warranted. 38 C.F.R. § 4.115a. Here, a May 2013 treatment record indicated the Veteran was wearing a diaper following his prostatectomy, but that he was unsure how long he would need to wear a diaper. By August 2014, the Veteran was no longer wearing a diaper or any other kind of pad for urine leakage. The Veteran's 100 percent rating was in effect until March 1, 2015. As such, during the May 2013 period where he was wearing a diaper following treatment for prostate cancer, he continued to be rated 100 percent for prostate cancer. As the leakage requiring a diaper was due to the prostate cancer surgery, a separate rating based on urinary leakage will not be provided concurrent to the 100 percent rating for prostate cancer to avoid pyramiding. During the January 2016 examination, the Veteran stated that he did have urine leakage, but he did not use absorbent material. As such, a rating under voiding dysfunction is not indicated. See 38 C.F.R. § 4.115a, voiding dysfunction. Obstructed voiding includes ratings ranging from noncompensable to 30 percent. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post- void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. Id. During the 2014 and 2016 examinations, the Veteran denied symptoms of obstructed voiding. VA treatment records do not show that the Veteran has sought treatment for obstructed voiding symptoms since his 2013 surgery. For urinary frequency, a 10 percent evaluation is warranted for daytime voiding interval between two and three hours or awakening to void two times per night. A 20 percent rating is warranted for daytime voiding interval between one and two hours or awakening to void three to four times per night warrants. A 40 percent rating is warranted for daytime voiding interval less than one hour or; awakening to void five or more times per night. Id. Although the Veteran denied urinary frequency during the 2014 examination, he reported he had increased urinary frequency following his prostatectomy during the 2016 examination. He reported daytime voiding frequency between one and two hours and waking to void two times per night. Based on his 2016 interview answers he warrants a 20 percent rating under 38 C.F.R. § 4.115a for urinary frequency. Diagnostic Code 7528 for malignant neoplasms of the genitourinary system specifically directed that residuals be rated based on voiding dysfunction or renal dysfunction, whichever is predominant. The Veteran has not reported compensable voiding dysfunction symptoms as his urine leakage does not require the use of absorbent materials. The Veteran has denied renal dysfunction. Treatment records do not include assessment for voiding dysfunction or renal dysfunction. As such, a 20 percent rating is assigned for residuals of prostate cancer based on urinary frequency. A rating in excess of 20 percent is not warranted as there was no indication that the Veteran has daytime voiding at intervals less than one hour or awakening to void five or more times per night, or that he requires the changing of absorbent materials two to four times per day (or greater); and there is no evidence that he has renal dysfunction or urinary tract infections. His 20 percent rating is based upon his interview during the 2016 examination. VA treatment records do not include complaints related to his urinary frequency, and there is no evidence VA has provided absorbent materials since March 1, 2015 (the period on appeal). The Board finds the Veteran's statements regarding his urinary frequency and voiding dysfunction to be credible and have provided the 20 percent rating based on these statements. Accordingly, the Board finds that a 20 percent rating for the Veteran's urinary frequency as a residual of prostate cancer has been met as of March 1, 2015 (the period on appeal). However, the Board finds that a preponderance of the evidence is against the claim of entitlement to a rating in excess of 20 percent. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. Additional Considerations During the Veteran's 2016 examination, he noted that he suffered from complete erectile dysfunction as a result of his radical prostatectomy. Under Diagnostic Code 7522, a 20 percent rating is for assignment where there is a deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. No other ratings are provided under Diagnostic Code 7522. Thus, to warrant a 20 percent rating under Diagnostic Code 7522, the Veteran's erectile dysfunction must have caused both (1) a deformity of the penis and (2) the loss of erectile power. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (indicating that use of the conjunctive 'and' in a statutory provision meant that all of the conditions listed in the provision must be met). Here, the evidence does not demonstrate, and the Veteran does not contend, that he has a deformity of the penis. As such, the criteria for assignment of a 20 percent rating under Diagnostic Code 7522 are not met. As such, the Veteran does not meet the requirements for a separate rating for erectile dysfunction secondary to his prostate cancer. A footnote to 38 C.F.R. § 4.115(b) indicates the disability is to be reviewed for entitlement to Special Monthly Compensation (SMC) for loss of use of a creative organ under 38 C.F.R. § 3.350 (a). SMC is payable if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C.A. § 1114 (k), 38 C.F.R. § 3.350 (a). It is VA policy to pay SMC for loss of use of a creative organ whenever a service connected disease causes loss of erectile power, "with or without penile deformity." M21-1MR, Part IV, Subpart ii, Chapter 2, Section H, Paragraph 39(b). Here, the 2016 examination included the Veteran's account that he cannot achieve and maintain an erection. The examiner indicated that the erectile dysfunction was a result of the Veteran's radical prostatectomy. Therefore, the Board concludes that SMC based on loss of use of a creative organ, is warranted. A review of the most recent rating codesheet does not indicate that SMC for loss of use of a creative organ had yet been granted. The Board will provide entitlement to SMC for loss of use as a separate disability related to the increased rating claim for prostate cancer. ORDER Entitlement to service connection for peripheral neuropathy is denied. Entitlement to service connection for a subdural hematoma, claimed as a brain aneurysm, secondary to PTSD, is denied. The reduction of the evaluation of the service-connected prostate cancer from 100 percent to noncompensable was proper. Entitlement to a rating in excess of 20 percent for urinary frequency as a residual of prostate cancer is denied. Entitlement to SMC for loss of use of a creative organ from April 16, 2013 is granted. REMAND Skin The Veteran's claim for an increased rating for his skin disorder was previously remanded in July 2014 for VA examinations. The July 2014 directives included a request for the examiner to "reconcile the current diagnosis(es) with the skin disorder for which service-connection was granted. See May 1996 Board decision and supporting medical evidence thereof. Please indicate whether each change in diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. Please support this opinion with a complete rationale." The directive requested that all acne, scars, and any other current skin disorders (to include eczema and hyperpigmentation) be described and addressed. The Veteran was afforded VA skin and scar examinations in March 2015. The skin examination included that the Veteran was service-connected for scars that resulted from his acne. At the time of the examination, the Veteran did not have any active acne. The examiner did not address his prior diagnoses of tinea cruris (diagnosed in the 2012 examination), eczema (diagnosed in the 2009 examination), and a skin disorder causing hyperpigmentation (noted on both the2009 and 2012 examinations). The examiner noted that he could not comment on the Veteran's acne as it was not present during the examination. "I would have to see patient with active acne lesions to comment on service-connection for this diagnosis." An addendum opinion noted that the Veteran did not have active evidence of acne or eczema and therefore the examiner could not provide an opinion on "eczema" without an active case to evaluate. "He would need to be re-examined when his eczema is active." The examiner again noted the Veteran was service-connected for "acne scarring," but that acne scarring and eczema were not related. The March 2015 VA scar examination provided details regarding the Veteran's "icepick scars" on his cheeks, which were noted to be the residuals of acne. The scar examination did not address the size and content of the Veteran's other scars (e.g. the scar on his neck, a scar on his chest, a possible cyst on his leg-which are all visible on photographs contained in the record). The Veteran's attorney has argued that the 2015 examinations are not adequate. The Board agrees that the skin examination is not adequate if the Veteran continues to have outbreaks of acne and eczema. Similarly, the scar examination is not accurate as it did not evaluate other scars present on the Veteran's body or indicate why they scars were not relevant (e.g. scar is not due to acne). As such, the claim for an increased rating for his skin disorder must be remanded to afford a skin examination during an active period of his skin disease, and an additional scar examination. This assumes that the Veteran's request for a higher rating for his skin disorder means that he continues to have active episodes. By way of history, the Veteran's claim for service connection for "chloracne" was granted by the Board in May 1996. In that decision, the Board granted service connection for "acne." The opinion noted that the Veteran had "cystic-type acne" and that a VA examiner had noted this acne was "like that seen with AO reaction." The December 1988 VA examination that the May 1996 grant was based upon included diagnoses of tinea pedis of his feet and cystic acne on his "face and back, like that seen with AO reaction." During the examination, the Veteran complained of lesions that come and go. He had "some scaling on both feet and the right sole there was some crusting indicating more recent activity." On his face he had two areas of "thickening hyperpigmentation" and dilated follicles in the front of each ear, about an inch in diameter. They were thickened and indicated he had some recurrence of acneform lesions in these areas of a cystic type. He had scattered discrete signs of previous lesions in the form of little thickenings and hyperpigmentation. He had a few cysts on his back which were not active, up to about a centimeter in diameter. The June 1996 rating decision which implemented the May 1996 Board grant of service connection provided a 10 percent rating under 7899-7806 for skin disorder, chloracne-form, face and back, secondary to AO exposure. Treatment records from the 1980s indicated the Veteran was treated for his acne with Accutane. Given this history, the Board notes that the Veteran was granted service connection for cystic acne. At the time of his initial examination he had evidence of cystic acne on his face and back; however, any active lesions related to his cystic acne or scars secondary to his cystic acne must be considered service-connected. Although the 1988 examination included a diagnosis of tinea pedis, service-connection for Athlete's foot was not granted at that time and no additional claim for service connection for tinea pedis has been received. On remand, during the VA skin examination, the examiner should indicate all active skin disorders and provide nexus opinions for all disorders other than cystic acne. Hypertension The Veteran has requested service connection for hypertension. A December 1988 treatment note indicated the Veteran had an assessment of high blood pressure for the past two years. The Veteran indicated his high blood pressure was a result of taking Accutane for his cystic acne. The Veteran has not been afforded a VA examination to address his service-connection claim. As he has indicated that his high blood pressure began as a result of medication taken for a service-connected skin disorder, a VA examination is warranted. PTSD A review of the record shows that the Veteran was treated for a subdural hematoma in April 2012, following a November 2011 motor vehicle accident. The Veteran's SSDI is based, in part, on the residuals of his subdural hematoma which has caused some cognitive impairments. Treatment records indicated that the Veteran complained of memory loss as a result of his subdural hematoma. However, records prior to his subdural hematoma included complaints related to memory and concentration. The most recent VA PTSD examination in March 2015 did not include mention of the subdural hematoma, only that the Veteran had diagnoses of PTSD and depression. As the March 2015 examination report did not include notation of the subdural hematoma or any resultant cognitive dysfunction, it also did not include whether any symptoms associated with the subdural hematoma could be distinguished from the Veteran's PTSD symptoms. The claim for an increased rating for PTSD must be remanded for an additional evaluation which includes a review of the VA treatment records and SSDI records, including records related to his 2012 subdural hematoma and two subsequent brain surgeries. TDIU and SMC The Veteran's claims of entitlement to TDIU and the discontinuance of his SMC at the housebound rate are intertwined with the outcome of his increased ratings claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA skin examination to be provided during an active phase of the Veteran's skin condition. The examiner is asked to please provide opinions on the following: (a) Please address the nature and diagnosis(es) of the Veteran's skin disorder(s). For purposes of this opinion, please reconcile the current diagnosis(es) with the skin disorder for which service-connection was granted. See May 1996 Board decision and supporting medical evidence thereof where the skin disorder granted was that of cystic acne related to AO exposure, also described as "chloracne-form" in the June 1996 rating decision. Please indicate whether each change in diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. Please support this opinion with a complete rationale. In so doing, the examiner is requested to attempt (to the extent possible) to distinguish the effects of the service-connected skin disorder and any skin disorder found to be a development of a new and separate condition. Please note if it is not possible to attribute the Veteran's symptoms to each disorder separately. The examiner's attention is invited to the 2009, 2012, and 2015 VA examinations. (b) Please address how each symptom impairs functionality, to include the ability to move. (c) Describe any acne present (i.e., whether papules, superficial cysts, pus-filled cysts), and indicate the location of each acne occurrence. (d) Please note the size of the area affected by each diagnosed skin disorder (e.g., scars, eczema, acne, lesions, hyperpigmentation) in square inches or square centimeters; (e) Please note the percentage of the entire body areas and the percentage of the exposed body areas affected by each diagnosed skin disorder (e.g., scars, eczema, acne, lesions, hyperpigmentation); (f) Please describe each medication used for each diagnosed skin disorder (i.e., whether the medication is topical, corticosteroid, etc.), and the duration for which each medication is required during the past 12-month period. The examiner must review the claims file and indicate in the examination report that this was accomplished. All opinions must be supported by a complete rationale. 2. Schedule the Veteran for a VA scar examination. The examiner is asked to provide measurements and assessments of all scars which were the result of his service-connected cystic acne, to include any scars on his back. 3. Schedule the Veteran for a VA examination to address his claim for service connection for hypertension. Following a review of the record and interview and examination of the Veteran, the examiner must provide the following opinions: (a) Is it at least as likely as not (50/50 probability or greater) that the Veteran's hypertension began during or is otherwise a result of his active service? (b) Is it at least as likely as not (50/50 probability or greater) that the Veteran's hypertension was caused by a service connected disability? In providing this opinion address the Veteran's contention that the Accutane he took to control his service-connected cystic acne caused him to develop high blood pressure. A complete rationale must be provided to support each opinion. 4. Schedule the Veteran for a VA PTSD examination. The examiner must review the claims file and interview and evaluate the Veteran. The examination report must include a statement as to whether the examiner can distinguish the symptoms associated with the Veteran's service-connected PTSD from the symptoms associated with his nonservice-connected 2012 subdural hematoma (and treatment, including brain surgeries). 5. Readjudicate the claim for an increased rating, and furnish the Veteran and his attorney a supplemental statement of the case if the matter is not resolved to the Veteran's satisfaction. Provide an opportunity to respond before the claim is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ KRISTI L. GUNN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs