Citation Nr: 1806186 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 09-50 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Whether the reduction in the rating from 20 percent to 10 percent for service-connected lumbar spine intervertebral disc syndrome (IVDS) with degenerative arthritic changes (lumbar spine disability), effective August 1, 2015, was proper. 2. Entitlement to a rating in excess of 20 percent for service-connected lumbar spine disorder. 3. Entitlement to service connection for a bilateral eye disorder. 4. Entitlement to service connection for a bilateral foot disorder. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1976 to February 1992. These matters are before the Board of Veterans' Appeals (Board) on appeal from February 2009, February 2013, and May 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In March 2014, the Veteran testified before a Decision Review Officer (DRO) at the RO. In November 2015, the Veteran testified during a Board hearing before a Veterans Law Judge at the Board's central office in Washington, D.C. Transcripts of both hearings are of record. In June 2016, the Board remanded the Veteran's appeal for further development. With regard to the claim for an increased rating for service-connected lumbar spine disorder, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the prior remand directives, and no further development is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for a bilateral eye disorder and a bilateral foot disorder are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran was in receipt of a 20 percent rating for service-connected lumbar spine disability from July 27, 2006, to July 31, 2015, a period of more than five years. 2. The September 2014 notification letter, the December 2014 rating decision, the December 2014 Supplemental Statement of the Case, the May 2015 rating decision, the May 2015 Supplemental Statement of the Case, and the August 2017 Supplemental Statement of the Case all failed to consider the provisions of 38 C.F.R. § 3.344. 3. For the entire appeal period, the Veteran's lumbar spine disability has not been manifested by forward flexion to 30 degrees or less, even with consideration of functional loss due to pain and other factors. There is also no evidence of ankylosis, either favorable or unfavorable, of the thoracolumbar spine or the entire spine, and there is no medical evidence showing IVDS of the thoracolumbar spine resulting in incapacitating episodes that had a total duration of at least four weeks during a twelve-month period. CONCLUSIONS OF LAW 1. Since the reduction of the rating for service-connected lumbar spine disability from 20 percent to 10 percent was not in accordance with applicable law and regulations, the criteria for restoration of the 20 percent rating are met, effective August 1, 2015. 38 U.S.C. §§ 1155, 5112 (2014); 38 C.F.R. §§ 3.105(e), 3.344, 4.1, 4.2, 4.13 (2017). 2. The criteria for a rating in excess of 20 percent for the Veteran's lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237-5243 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist with respect to the issues decided on the merits below. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Rating Reduction Congress has provided that a Veteran's disability will not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. When an AOJ reduces a rating without following the applicable regulations, the reduction is void ab initio. Greyzck v. West, 12 Vet. App. 288, 292 (1999). Initially, where the reduction in evaluation of a service-connected disability or employability status 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 will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. If additional evidence is not received within that period, 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 beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). In the instant case, the AOJ complied with § 3.105(e) in a September 2014 letter. For reductions in ratings to be properly accomplished, specific requirements must be met. See 38 C.F.R. § 3.344; see also Dofflemyer, 2 Vet. App. 277 (1992). In regard to disability ratings in effect for a period of 5 years or more, the provisions of 38 C.F.R. § 3.344(a) and (b) are for application. See 38 C.F.R. § 3.344(c). Where a veteran's schedular rating has been both stable and continuous for 5 years or more, the rating may be reduced only if the examination on which the reduction is based is at least as full and complete as that used to establish the higher evaluation. 38 C.F.R. § 3.344(a). Ratings for disease subject to temporary or episodic improvement will not be reduced on the basis of any one examination, except in those instances where the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Id. Moreover, though material improvement in the mental or physical condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. Id. In considering the propriety of a reduction, VA must focus on the evidence of record available to the AOJ at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition has demonstrated actual improvement. Cf. Dofflemyer, 2 Vet. App. at 281-82. Care must be taken, however, to ensure that a change in an examiner's evaluation reflects an actual change in the Veteran's condition, and not merely a difference in the thoroughness of the examination or in descriptive terms, when viewed in relation to the prior disability history. 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 38 C.F.R. §§ 4.1, 4.2, 4.13; see also Brown, 5 Vet. App. at 420-22; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Significantly, in a rating reduction case, VA has the burden of establishing that the disability has improved. See Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991). Historically, a June 2007 rating decision granted service connection for lumbar spine disability, and assigned a 20 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2017), effective July 27, 2006. In October 2008, the Veteran filed a claim for an increased rating for her service-connected lumbar spine disability. A September 2014 rating decision proposed to reduce the Veteran's rating for her service-connected lumbar spine disability from 20 percent to 10 percent based on November 2011 and April 2014 VA examination reports. In October 2014, the Veteran requested a personal hearing. In a December 2014 rating decision, the AOJ reduced the rating for the Veteran's lumbar spine disability from 20 to 10 percent, effective April 1, 2015, based on the November 2011 and April 2014 VA examination reports. In a January 2015 letter, the AOJ acknowledged the Veteran's October 2014 hearing request, and stated that the December 2014 rating decision was void. In March 2015, the Veteran was afforded a hearing before a Decision Review Officer (DRO). In a May 2015 rating decision, the AOJ reduced the rating for the Veteran's lumbar spine disability from 20 to 10 percent, effective August 1, 2015, based on the November 2011 and April 2014 VA examination reports. Because the Veteran's 20 percent rating had been in effect more than five years at the time of the May 2015 rating decision, 38 C.F.R. § 3.344 (a) and (b) are applicable. However, the September 2014 notification letter, the December 2014 rating decision, the December 2014 Supplemental Statement of the Case, the May 2015 rating decision, the May 2015 Supplemental Statement of the Case, and the August 2017 Supplemental Statement of the Case all fail to reflect consideration of the provisions of 38 C.F.R. § 3.344. Specifically, these AOJ decisions all fail to address whether the November 2011 and April 2014 VA examination reports were as full and complete as the examination upon which the original rating was established. Additionally, these AOJ decisions all fail to discuss whether the evidence demonstrated a material improvement that would be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a); Kitchens v. Brown, 7 Vet. App. 320 (1995). The Board emphasizes that failure to consider and apply the provisions of 38 C.F.R. § 3.344, if applicable, renders a rating decision void ab initio as such omissions are error and not in accordance with the law. See Greyzck, 12 Vet. App. at 292. See also Hayes v. Brown, 9 Vet. App. 67, 73 (1996); Dofflemyer, 2 Vet. App. 277. Accordingly, the 20 percent disability rating for the Veteran's service-connected lumbar spine disability is restored, effective August 1, 2015. III. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.40. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2014); DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. (quoting 38 C.F.R. § 4.40). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. On October 30, 2008, VA received the Veteran's claim for an increased rating for her lumbar spine disability. Although the Veteran's lumbar spine disability is rated under Diagnostic Code 5243, all spine disabilities are rated, primarily, pursuant to the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. The General Rating Formula provides for assignment of a 20 percent rating when forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; if the combined range of motion for the thoracolumbar spine is not greater than 120 degrees; or if muscle spasm or guarding is 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 warranted when forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or when favorable ankylosis of the entire thoracolumbar spine is present. A 50 percent rating is warranted when unfavorable ankylosis of the entire thoracolumbar spine is present. Finally, a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. The "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a (Plate V) indicates that normal range of motion of the thoracolumbar spine encompasses flexion to 90 degrees, and extension , bilateral lateral flexion, and bilateral rotation all to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The Notes following the General Rating Formula provide further guidance for rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Alternatively, the Formula for Rating IVDS Based on Incapacitating Episodes provides a 20 percent disability rating for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. Pertinent evidence includes VA treatment records, VA examination reports from December 2008, November 2011, April 2014, and May 2017, and the Veteran's lay statements. In September 2008, the Veteran reported pain in her lower back/lumbar spine region, which she rated as a five out of ten. She reported that movement and the weather made her pain worse, and that there was nothing which provided relief. In December 2008, the Veteran underwent a VA examination. She reported stiffness and numbness in her spine, but she denied any loss of bladder or bowel control. She also reported pain, which was described as crushing, squeezing, aching, and sticking. She rated her pain as a six out of ten, and stated that it was brought on by physical activity. She used medication to deal with the pain, but she denied any periods of incapacitation. Concerning her functional impairment, she reported problems with muscle spasms, stiffness, and pressing, and indicated that it was hard to bend sometimes and push herself back up. Upon examination, her posture and gait were normal. There was no evidence of spasms, tenderness, or ankylosis. Range-of-motion testing revealed the following: flexion to 80 degrees, with objective evidence of pain at 80 degrees; extension to 20 degrees, with objective evidence of pain at 20 degrees; right lateral flexion to 30 degrees; left lateral flexion to 30 degrees; right lateral rotation to 30 degrees; and left lateral rotation to 30 degrees. Following repetitive use, the Veteran's functional ability, including her range of motion, was not further limited by pain, fatigue, weakness, incoordination, or a lack of endurance. The examiner noted that she suffered from IVDS, but there was no evidence of any bowel or bladder dysfunction. Concerning the functional effects of the Veteran's disability, the examiner noted that she was an assembly line worker, and that she would occasionally experience back spasms and stiffness. She was diagnosed with IVDS with degenerative arthritis changes. A July 2009 VA treatment record noted that there was no deformity of the lumbar spine, that it was tender to palpation, and that the Veteran exhibited full range of motion. An August 2009 VA treatment record noted the Veteran's report of chronic non-traumatic low back pain. Upon examination, there was no spasm or deformity with paraspinal muscle tenderness. A November 2009 VA treatment record noted the Veteran's complaint of back pain. The treatment provider noted that her back pain was chronic, and that a previous MRI had revealed disc disease. A November 2010 VA treatment record noted the Veteran's report of a constant dull pain in her back, which she rated as a seven out of ten. A May 2011 VA treatment record noted that the Veteran's trunk range of motion toe touch was successful, but that she reported pain throughout the evaluation. A July 2011 VA treatment record noted that the Veteran had a small posterior annular tear and mild disc bulge at L4-5. The treatment provider noted that this was a minor abnormality. A September 2011 VA treatment record noted that the Veteran denied back pain, joint pain, and muscle pain. In November 2011, the Veteran underwent another VA examination. She reported being able to walk without limitation, and denied any falls. Her symptoms included stiffness and spasms. She denied fatigue, decreased motion, paresthesia, numbness, and weakness, and she also denied and bowel or bladder problems. Concerning pain, she described it as a constant, localized pain, which was characterized as moderate. Her pain was exacerbated by physical activity, and was relieved by rest and medication. She also denied any periods of incapacitation and flare ups. Upon examination, range-of-motion testing revealed the following: flexion to 90 degrees or greater; extension to 30 degrees or greater; right lateral flexion to 30 degrees or greater; left lateral flexion to 30 degrees or greater; right lateral rotation to 30 degrees or greater; and left lateral rotation to 30 degrees or greater. Following repetitive use, the Veteran's functional ability, including her range of motion, was not further limited by pain, fatigue, weakness, incoordination, or a lack of endurance. There was no evidence of localized tenderness or pain to palpation, and there was no evidence of guarding or muscle spasm. Muscle strength testing, reflex testing, and sensory examination was normal. There was no evidence of neurological abnormalities. Although the examiner noted the diagnosis of IVDS in the past, there was no evidence of such during the examination. Concerning any functional impairment, the examiner noted that the Veteran's ability to work was affected as a result of pain on constant bending and lifting. A May 2012 VA treatment record noted the Veteran's reported of lower back pain that began three days prior. She stated that it was painful to move or lie down. Upon examination, there was moderate lumbar tenderness, but evidence of deformity. Her strength was normal. In December 2013, the Veteran was seen for back pain. She denied incontinence, and indicated that she was ambulating well. Upon examination, the treatment provider noted a positive sign of chronic back pain with flare-ups that worsened with standing. A January 2014 VA treatment record noted the Veteran's reports of chronic low back pain, which she rated as a one out of 10. She stated that the pain was worsened by walking and standing. Upon examination, there was no deformity, there was tenderness over the midline lower lumbar spine, and she exhibited full range of motion. In April 2014, the Veteran underwent another VA examination. She reported missing five days of work due to back pain. Upon examination, range-of-motion testing revealed the following: flexion to 80 degrees; extension to 30 degrees or greater; right lateral flexion to 30 degrees or greater; left lateral flexion to 30 degrees or greater; right lateral rotation to 30 degrees or greater; and left lateral rotation to 30 degrees or greater. Following repetitive use, the Veteran's functional ability, including her range of motion, was not further limited by pain, fatigue, weakness, incoordination, or a lack of endurance. Furthermore, her functional ability was not further limited during flare-ups. There was no evidence of localized tenderness or pain to palpation, and there was no evidence of guarding or muscle spasm. Muscle strength testing, reflex testing, and sensory examination was normal. There was no evidence of neurological abnormalities. Although the examiner noted the diagnosis of IVDS, there was no evidence of such during the examination. Concerning any functional impairment, the examiner concluded that her lumbar spine disorder did not impact her ability to work. In March 2015, the Veteran testified before a DRO. She reported problems with her back including have to take time off of work due to pain. She also reported problems with daily activities, including taking more time in the morning to get dressed and get moving due to pain. In November 2015, the Veteran testified before the undersigned Veterans Law Judge. She reported constant pain due to standing all day, as well as increased pain if she ran. In May 2017, the Veteran underwent another VA examination. She reported problems with flare ups and stiffness, as well as trouble getting out of bed. Flare ups consisted of stiffness, sharp pains, and muscle spasms. She also reported problems moving at a normal pace during flare-ups. Range-of-motion testing revealed the following: flexion to 60 degrees; extension to 20 degrees; right lateral flexion to 15 degrees; left lateral flexion to 20 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. Although there was pain on examination, such did not result in or cause any additional functioning loss. There was no evidence of pain with weight bearing. Following repetitive use, the Veteran's functional ability and range of motion remained the same. The examiner noted that the examination results were consistent with the Veteran's lay statements concerning her functional ability during flare ups. There was no localized tenderness, guarding, or muscle spasms, and there were no additional contributing factors contributing to her disability. Muscle strength testing, reflex examination, and sensory examination were all normal, and there was no evidence of ankylosis. The examiner noted that she suffered from IVDS, but there were no incapacitating episodes over the last twelve months. There were no other pertinent findings related to his lumbar spine disability. With regard to any functional impairment on his ability to work, the examiner noted that that she had trouble bending and lifting. After a careful review of all the evidence, the Board finds that at no time during the pendency of the appeal has the Veteran's lumbar spine disability more nearly approximated the criteria for a higher rating under any applicable diagnostic codes. With regard to the General Rating Formula, the evidence demonstrates that the Veteran's lumbar spine range of motion has not been limited to 30 degrees or less, even with consideration functional loss due to pain or due to weakness, fatigability, incoordination, and pain on movement; to the contrary, December 2008, November 2011, April 2014, and May 2017 VA examiners specifically note that the Veteran's range of motion was not further limited after repetitive use. Furthermore, at no time during the pendency of the appeal has the evidence demonstrated that she suffers from ankylosis, favorable or unfavorable, of the thoracolumbar spine or the entire spine. As such, she is not entitled to a disability rating in excess of 20 percent under the General Rating Formula. The Board also finds that, at no time during the appeal period has his lumbar spine disability resulted in any neurological manifestations, such as a bowel or bladder impairment, for which service connection has not already been granted. With regard to the Formula for Rating IVDS, while each VA examiner noted the diagnosis of IVDS, all concluded that such did not result in incapacitating episodes at any point during the previous twelve months. Moreover, there is nothing in the medical that suggests that the Veteran's IVDS resulted in incapacitating episodes requiring bed rest prescribed by a physician. In fact, the Veteran has repeatedly denied experiencing any incapacitating episodes. Thus, at no point during the pendency of the appeal has IVDS of the lumbar spine disability resulted in incapacitating episodes have a total duration of at least four weeks, but no more than six weeks, the criteria for a higher rating under Diagnostic Code 5243. In assessing the severity of the Veteran's lumbar spine disability, the Board has considered her assertions regarding her symptoms, which she is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, she has not alleged that her forward flexion is less than that shown on examination, or that she has ankylosis of the thoracolumbar spine or entire spine. In addition, the criteria necessary to substantiate a higher rating for IVDS includes bed rest prescribed by a physician which is not shown by the evidence of record. Thus, and as noted above, the Veteran's lay statements cannot serve to satisfy these criteria, and the Board must rely on the medical evidence of record. As such, her lay assertions do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran's service-connected thoracolumbar spine disability; however, her symptomatology has been stable for the disability rating currently assigned throughout the appeal period. Therefore, assigning further staged ratings is not warranted. Neither the Veteran nor her 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, 369-370 (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). In sum, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for her service-connected thoracolumbar spine disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against a higher rating, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. ORDER Restoration of the 20 percent rating for service-connected lumbar spine disability is granted, effective August 1, 2015. A rating in excess of 20 percent for service-connected lumbar spine disability is denied. REMAND In the March 2016 remand, the Board directed the AOJ to schedule the Veteran for VA examinations to determine whether her bilateral eye disorder and/or her bilateral foot disorder were related to her military service. With regard to her bilateral eye disorder, the Board specifically requested that the examiner address whether any bilateral eye disorder was a congenital or developmental defect that was subject to a superimposed disease or injury during service, to include having gasoline sprayed in her eyes and being hit in the back of the head by a two by four. For any disorder that was not congenital or developmental, the examiner was to address whether such was at least as likely as not related to her military service, to include having gasoline sprayed in her eyes and being hit in the back of the head by a two by four. With regard to any bilateral foot disorder, the Board specifically requested that the examiner address whether such was related to her military service, to include performing physical activity while wearing combat boots. In offering the opinion, the examiner was to consider all evidence of record, including the Veteran's lay statements concerning the onset and continuity of symptoms, and was to provide an adequate rationale. In May 2017, the Veteran underwent a VA examination. With regard to her eyes, she was diagnosed with dry eyes and cataracts. The examiner opined that such was not related to having gasoline sprayed in her eyes and being hit in the back of the head by a two by four. The examiner then listed the common cases of dry eyes and cataracts, and noted that there was no documentation of persistent dry or irritated eyes following the gasoline incident or being hit in the head with a two by four. With regard to her feet, she was diagnosed with flat feet and plantar fasciitis. The examiner opined that such was not related to her military service, to include performing physical activity while wearing combat boots. The examiner noted that her occupation following service placed increased stress and strain on her feet, and she did not seek treatment until 2010 for her foot problems. The examiner reasoned that, based on the negative exam findings during and after service, there was no correlation between her current foot conditions and her military service. Unfortunately, the Board finds that both are inadequate. Initially, the Board finds that the examination failed to substantially comply with the March 2016 remand directives because the examiner failed to address whether any bilateral eye disorder was a congenital or developmental defect that was subject to a superimposed disease or injury during service, as was requested. See Stegall v. West, 11 Vet. App. 268 (1998). Furthermore, the opinions merely rely on the absence of in-service and post-service treatment for a bilateral eye disorder and/or bilateral foot disorder, and fail to reflect consideration of the Veteran's lay statements concerning the onset and continuity of symptoms associated with these issues. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (a VA examination opinion must reflect consideration of lay evidence of both in-service incurrence and/or continuity of symptomatology since service). The United States Court of Appeals for Veterans Claims has held that a medical examination report must not contain only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Therefore, to insure that all pertinent evidence is adequately considered, the Board finds that he should be afforded a new VA examination. On remand, the AOJ should also obtain any outstanding VA treatment records. Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, the Veteran should be provided the opportunity to identify any private treatment records that are relevant to his claims, and to provide the necessary information in order for the VA to assist him in obtaining these potentially relevant records. See 38 C.F.R. § 3.159(c) (2017). Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Contact the Veteran and request authorization to obtain any outstanding records pertinent to her claims. Make at least two (2) attempts to obtain records from any identified source. 3. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 4. After obtaining all outstanding records, the Veteran should be afforded an appropriate VA examination to determine whether any bilateral eye disorder is related to her military service. The entire claims file must be made available to the examiner and the examination report should include discussion of the Veteran's in-service health history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Following a review of the record, to include the Veteran's lay statements, the examiner should answer the following: a) The examiner should identify all currently diagnosed bilateral eye disorders, including dry eyes and cataracts: b) For any congenital or developmental defect diagnosed, is it as least as likely as not (i.e. a 50 percent probability or more) that any such defect was subject to a superimposed disease or injury during the Veteran's service, to include having gasoline sprayed in her eyes and/or being hit on the back of the head with a two by four? c) For any diagnosed eye disorder which is NOT a congenital or developmental defect, is at least as likely as that any such disorder is due to the Veteran's service, to include having gasoline sprayed in her eyes and/or being hit on the back of the head with a two by four? In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding in-service incurrence and continuity of symptomatology. The examiner's opinion must reflect consideration of the Veteran's reports as to her history and symptomatology. If the examiner chooses to reject her reports, the examiner must provide a reason for doing so, and her lay statements must not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered together with the other evidence of record. A clearly-stated rationale for any opinion offered should be provided and must not be based on the lack of evidence of a bilateral eye disorder in her service treatment records. 5. After obtaining all outstanding records, the Veteran should be afforded an appropriate VA examination to determine whether any bilateral foot disorder is related to her military service. The entire claims file must be made available to the examiner and the examination report should include discussion of the Veteran's in-service health history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Following a review of the record, to include the Veteran's lay statements, the examiner should answer the following: Is it at least as likely as not (50 percent or greater probability) that any bilateral foot disorder is related to the Veteran's military service, to include performing physical activity while wearing combat boots. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding in-service incurrence and continuity of symptomatology. The examiner's opinion must reflect consideration of the Veteran's reports as to her history and symptomatology. If the examiner chooses to reject her reports, the examiner must provide a reason for doing so, and her lay statements must not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered together with the other evidence of record. A clearly-stated rationale for any opinion offered should be provided and must not be based on the lack of evidence of a bilateral foot disorder in her service treatment records. 6. Thereafter, and after any further development deemed necessary, the issues on appeal should be reajudicated. If the benefit sought on appeal is not granted, the Veteran should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2014). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs