Citation Nr: 18140717 Decision Date: 10/05/18 Archive Date: 10/05/18 DOCKET NO. 16-19 671A DATE: October 5, 2018 ORDER Entitlement to an initial 30 percent for the period prior to February 15, 2015 for tinea cruris pedis and corporis with onychomycosis is granted. Entitlement to an initial rating in excess of 60 percent for the period from February 15, 2015 to May 19, 2016 for tinea cruris pedis and corporis with onychomycosis is denied. Entitlement to an initial rating in excess of 30 percent for the period since May 20, 2016 for tinea cruris pedis and corporis with onychomycosis is denied. REMANDED Entitlement to an initial rating in excess of 30 percent for headaches is remanded. FINDINGS OF FACT 1. For the period prior to February 15, 2015, the Veteran’s tinea cruris pedis and corporis with onychomycosis covered 5 to 20 percent of the entire body and exposed areas which required systemic therapy for a total duration of six weeks. 2. For the period from February 15, 2015 to May 19, 2016, the Veteran’s tinea cruris pedis and corporis with onychomycosis covered over 40 percent of the total body area. 3. For the period since May 20, 2016, the Veteran’s tinea cruris pedis and corporis with onychomycosis covers 20 to 40 percent of the entire body and has been treated by topical anti-fungal creams only. CONCLUSIONS OF LAW 1. For the period prior to February 15, 2015, the criteria for an initial 30 percent rating for tinea cruris pedis and corporis with onychomycosis have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, Diagnostic Codes 78103-7806 (2017) 2. For the period from February 15, 2015 to May 19, 2016, the criteria for an initial rating in excess of 60 percent for tinea cruris pedis and corporis with onychomycosis have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, Diagnostic Codes 78103-7806 (2017). 3. For the period since May 20, 2016, the criteria for an initial rating in excess of 30 percent for tinea cruris pedis and corporis with onychomycosis have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, Diagnostic Codes 78103-7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1966 to June 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2013, September 2014 and May 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In the May 2016 rating decision, the RO granted service connection for tinea corporis and combined this with the 10 percent evaluation for tinea cruris and pedis with onychomycosis, effective March 8, 2007. Additionally, the rating decision granted an increased 60 percent rating for a skin disability, effective February 15, 2015 and then granted a 30 percent rating for a skin disability, effective May 20, 2016. The Board notes that the increases to 60 and 30 percent for the skin disability did not constitute full grant of the benefits sought. Accordingly, the issues of entitlement to a rating in excess of 60 percent for a skin disability for the period from February 15, 2015 to May 19, 2016 and a rating in excess of 30 percent for the period from May 20, 2016 remain in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board notes that in September 2014, the Board remanded the issue of entitlement to an effective date earlier than May 9, 2013, for a 10 percent rating for tinea cruris for the issuance of a statement of the case. Subsequently, a September 2015 rating decision granted an earlier effective date of March 8, 2007 which was the specific date requested by the Veteran in his claim for an earlier effective date. As a result, this issue is no longer before the Board. The Board also acknowledges that the issue of entitlement to a rating in excess of 20 percent for bilateral hearing loss has been perfected, but not yet certified to the Board. The Board’s review of the claims file reveals that the agency of original jurisdiction (AOJ) is still clearly taking action on this issue and it has not been certified for appeal. As such, the Board will not accept jurisdiction over it at this time, but it will be the subject of a subsequent Board decision, if otherwise in order. Increased Rating Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2017). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2017). The Veteran’s skin disabilities are rated under Diagnostic Codes 7813-7806 for dermatitis or eczema. (Diagnostic Code 7813 pertains, in relevant part, to tinea cruris, and refers to the criteria of Diagnostic Code 7806.) Pursuant to Diagnostic Code 7806, a 10 percent rating is assigned when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas is affected, or; when intermittent systemic therapy such as corticosteroids or immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent rating is assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 60 percent rating is assigned where there more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. Id. Recently, VA amended the criteria for rating the skin. Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, “systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.” Diagnostic Code 7806 continues to apply to dermatitis or eczema, but is rated under the general rating formula for the skin. Under the general rating formula, a 10 percent rating is warranted where at least one of the following is present: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted where at least one of the following is present: Characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. With regard to the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the Court in Johnson v. McDonald, 27 Vet. App. 497, 505 (2016) held that use of a topical steroid constituted “systemic therapy” within the meaning of Diagnostic Code 7806. In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit reversed this decision and determined that “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs” under Diagnostic Code 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, No. 16-2037, 2018 U.S. App. Vet. Claims Lexis 1314 (Sept. 28, 2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. Significantly, with regard to the effective date of the new criteria, VA indicated in the Supplementary Information to the Final Rule that its “intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied.” The Veteran’s claim in this case was pending prior to the August 13, 2018 effective date of the new criteria, and therefore the Board will consider both the old and new criteria and apply the more favorable. However, the Federal Circuit’s interpretation of the term “systemic therapy” in the old criteria applies throughout the entire period prior to the August 13, 2018 effective date of the new criteria. Rivers v. Roadway Express, 511 U.S. 298, 312-13 (1994) (“[j]udicial construction of a statute [or regulation] is an authoritative statement of what the statute [or regulation] meant before as well as after the decision of the case giving rise to that construction”); Jordan v. Nicholson, 401 F.3d 1296, 1298-99 (Fed. Cir. 2005) (a new interpretation of a statute retroactively affects decisions still open on direct review); Threatt v. McDonald, 28 Vet. App. 56, 63 (2016) (noting the “normal principle at this Court that judicial decisions operate retrospectively”). Factual Background and Analysis A February 2009 VA dermatology consult noted that the Veteran had a rash on his groin, buttocks and umbilicus area. The diagnosis was tinea corporis. The Veteran underwent a VA examination in March 2011. The examiner noted that the Veteran reported various rashes over the years involving his groin, buttocks, back, face and feet. The condition had been continuous over the years and not progressive. He was not on any current corticosteroids or immunosuppressants. He had old prescriptions from topical terbinafine and hydrocortisone creams. Local systems were itching of the skin and there were no systemic symptoms. The only areas currently involved were his groin and feet. There was no malignancy and no impairment of function. On examination, there was erythematous dermatitis in the upper inner thighs and peri-scrotal area consistent with tinea cruris and also perianal erythema. There was no evidence of eczema or excessive dryness of the buttocks. The toenails of each feet were involved with onychomycosis. There was no rash on the trunk, face, arms or elsewhere. The percentage of exposed body area affected was 0 percent and the percentage of the entire body area affected was 1 percent. The diagnosis was tinea cruris and onychomycosis. The Veteran underwent a VA examination in May 2013. The examiner noted a long history of groin rash, tinea pedis and onychomycosis. In 2009 the Veteran was given a 6 week course of Griseofulvin which suppressed his fungal disease for about 3 years but it had now recurred with a primary complaint of itching of the groin area and feet. Topical antifungal medications had not been effective in the past. None of the skin conditions involved the head, face or neck and he did not have any benign or malignant skin neoplasms. He had not been treated in the past 12 months with oral or topical medications and had no other treatments during this time. He had not had any debilitating or non-debilitating episodes in the past 12 months. On examination, his body had no infections of the skin of exposed areas but had 5 to 20 percent of the total body area that had skin infections. He had a papular rash in the groin and proximal thigh area. There was also mild post inflammatory hyperpigmentation in the same region. There was no penile lesion and no buttock rash. He had erythema and skin flaking on the dorsums of his feet. There was also maceration and skin cracking between and under his 4th and 5th toes. In a February 2015 correspondence, a private physician noted that the Veteran had 55 percent of his body surface covered by tinea corporis. The Veteran underwent a VA examination in May 2016. The Veteran reported having a long history of a pruritic skin rash which had affected his trunk, lower extremities and feet. It had affected his face and scalp at times but currently affected primarily the groin, buttocks and lower extremities. He had used multiple topical preparations which had helped only transiently. At one point he took a pill (Griseofulvin) for the rash which helped dramatically for several years but the rash recurred. He currently used topical clotrimazole. None of the Veteran’s skin conditions caused scarring on the head, face or neck. He did not have benign or malignant skin neoplasms and did not have any systemic manifestations due to any skin disease. Over the past 12 months, the Veteran had been treated with constant or near constant topical clotrimazole cream. He had not had any debilitating or non-debilitating episodes in the past 12 months. On examination, his body had no infections of the skin of exposed areas but had 20 to 40 percent of the total body area that had skin infections. His skin disabilities did not impact his ability to work. 1. Period Prior to February 15, 2015 After careful review of the evidence, the Board finds that for the period prior to February 15, 2015, the evidence shows that a rating of 30 percent for is warranted based on required systemic therapy for a total duration of six weeks. Notably, the evidence does not indicate that at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas were affected to warrant an initial 30 percent rating. As noted above the March 2011 VA examination demonstrated that the percentage of exposed body area affected was 0 percent and the percentage of the entire body area affected was 1 percent while the May 2013 VA examination only demonstrated that the exposed body area affected was 0 percent with 5 to 20 percent of the total body area that had skin infections. However, the record demonstrates that the Veteran required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during a 12-month period. As noted above, the May 2013 VA examiner indicated that in 2009 the Veteran was given a 6 week course of Griseofulvin which suppressed his fungal disease for about 3 years. The Board finds that the use of Griseofulvin (an oral antifungal medication) for a 6 week period warrants the assignment of an initial 30 percent rating for the period prior to February 15, 2015. As noted above, the Federal Circuit in Johnson v. Shulkin found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole.” However, an initial rating in excess of 30 percent for the period prior to February 15, 2015 is not warranted. In order to warrant the next higher rating of 60 percent rating (the highest available under Diagnostic Code 7806), there must be a showing that more than 40 percent of the entire body or exposed areas are affected, or that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. Under the new criteria, a 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. As reflected above, for the period prior to February 15, 2015, the Veteran’s skin disability at most demonstrated 5 to 20 percent of the total body area that was infected. Additionally, there is no evidence that the Veteran’s skin disability required constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over a 12-month period. Accordingly, an initial rating of 30 percent but no higher is warranted for the period prior to February 15, 2015. 2. February 15, 2015 to May 19, 2016 The Board finds that an initial rating for tinea cruris pedis and corporis with onychomycosis higher than 60 percent is not warranted for the period from February 15, 2015 to May 19, 2016. As noted above, a 60 percent rating is the maximum rating allowable under Diagnostic Code 7806. Additionally, no higher or alternative rating under a different diagnostic code can be applied. The only applicable diagnostic codes for disabilities of the skin that would provide a potentially higher rating, Diagnostic Codes 7800 and 7817, are inapplicable here, as the Veteran does not have visible or palpable tissue loss to the head, face, or neck, or systemic manifestations (such as fever, weight loss, and hypoproteinemia) necessary to obtain a higher rating under those diagnostic codes. The Veteran also does not otherwise have diagnoses or symptoms that more closely approximate those necessary for a separate rating under 38 C.F.R. § 4.118, Diagnostic Codes 7807 to 7833. Because the Veteran is already receiving the maximum allowable rating under Diagnostic Code 7806, and because there are no other relevant diagnostic codes available for a higher evaluation, an initial rating in excess of 60 percent for the Veteran’s tinea cruris pedis and corporis with onychomycosis disability for the period from February 15, 2015 to May 19, 2016 is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 60 percent for tinea cruris pedis and corporis with onychomycosis for the period from February 15, 2015 to May 19, 2016. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). 3. Period from May 20, 2016 The Board finds that an initial rating for tinea cruris pedis and corporis with onychomycosis higher than 30 percent for the period from May 20, 2016 is not warranted. Again, in order to warrant the next higher rating of 60 percent rating (the highest available under Diagnostic Code 7806), there must be a showing that more than 40 percent of the entire body or exposed areas are affected, or that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. Under the new criteria, a 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. As reflected above, for the period since May 20, 2016 the Veteran’s skin disability at most demonstrated 20 to 40 percent of the total body area that was infected as reflected on the May 2016 VA examination. Additionally, there is no evidence that the Veteran’s skin disability required constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over a 12-month period. In this regard, the only medications shown to be prescribed during this time period is an antifungal (clotrimazole) topical medication. While the May 2016 VA examiner specifically noted that the Veteran had been treated with constant or near constant topical clotrimazole cream, the topical antifungal cream that the Veteran used (clotrimazole) is not a corticosteroid or immunosuppressive drug. Moreover, the topical antifungal cream clotrimazole is not like or similar to a corticosteroid or immunosuppressive drug. See Warren v. McDonald, No. 28 Vet. App. 194 (2016) (under Diagnostic Code 7806, “[c]ompensation is available for all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs”). In that decision, the Court relied on the VA Adjudication Procedure Manual (M21-1), for the definition of “systemic therapy,” as “any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder.” Id. at n.2. Medical dictionaries have defined “systemic” therapy as pertaining to or affecting the body as a whole. See, e.g., Dorland’s Illustrated Medical Dictionary 1848 (32nd ed. 2012). A corticosteroid is “any of the 21-carbon steroids elaborated by the adrenal cortex... in response to corticotropin released by the pituitary gland or to angiotensin.” Id. at 425. Corticosteroids “are used clinically for hormonal replacement therapy, for suppression of ACTH secretion by the anterior pituitary, as antineoplastic, anti-allergic, and anti-inflammatory agents, and to suppress immune responses.” Id. An immunosuppressive or immunosuppressant agent is “an agent capable of suppressing immune responses.” Id. at 915. Clotrimazole is a “broad-spectrum antifungal agent.” Id. at 379. An antifungal medication is “an agent that is destructive to fungi.” Id. at 102. Despite the fact that the list of systemic therapies included in Diagnostic Code 7806 is not exhaustive, topical antifungal cream is not “like or similar to corticosteroids or other immunosuppressive drugs.” Additionally, there is again no evidence that the Veteran’s skin disability required constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over a 12-month period. In sum, the Veteran’s skin condition resulting from his tinea cruris pedis and corporis with onychomycosis has only affected 20 to 40 percent of the total body area for the period since May 20, 2016. Further, the May 2016 examiner specifically noted that the Veteran did not have any systemic manifestations due to any skin disease (such as fever, weight loss, and hypoproteinemia). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 30 percent for tinea cruris pedis and corporis with onychomycosis for the period since May 20, 2016. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claim remaining on appeal. the Board notes that the last VA examination for his service-connected headache disability took place in March 2011. However, in an October 2017 correspondence, the Veteran’s representative indicated that the service-connected headache disability had worsened as it was noted that the Veteran’s employer provided a January 2016 statement which noted that the Veteran had to take off work due to his migraine headaches Given that the Veteran indicated that his service-connected headache symptoms had worsened and he appears to be receiving continued treatment for this disability, the Board is of the opinion that a new VA examination would be probative. Although a new VA examination is not warranted based merely upon the passage of time [see Palczewski v. Nicholson, 21 Vet. App. 174 (2007)], the Court has held that where a veteran claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, the VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Therefore, to ensure that the record reflects the current severity of the Veteran’s service-connected headache disability, a contemporaneous examination is warranted, with findings responsive to the applicable rating criteria. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered contemporaneous”). The matter is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Thereafter, the Veteran should also be scheduled for a VA examination before an appropriate physician to determine the current level of severity of his service-connected headache disability. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination report should reflect review of these items. All necessary tests and studies should be performed, and the examiner should describe in detail all symptomatology associated with the Veteran’s headache disability. The examiner should also provide an opinion concerning the impact of the Veteran’s service-connected headache disability on his ability to work. 3. After completion of the above and any additional development deemed necessary, the issue on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James A. DeFrank, Counsel