Citation Nr: 18145286 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 16-09 761 DATE: October 26, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for breathing problems is denied. Entitlement to an initial disability rating higher than 40 percent for a lower back disability is denied. Entitlement to earlier effective dates for the grants of service connection for a lower back disability, a bilateral hip disability, a bilateral knee disability with shin splints, and tinnitus, is denied. REMANDED Entitlement to an initial rating higher than 10 percent for a right hip disability, based on limitation of adduction, is remanded. Entitlement to an initial rating higher than 10 for a right hip disability, based on limitation of flexion, is remanded. Entitlement to an initial rating higher than 10 percent for a left hip disability, based on limitation of adduction, is remanded. Entitlement to an initial rating higher than 10 for a left hip disability, based on limitation of flexion, is remanded. Entitlement to an initial compensable rating for a right knee disability with shin splints is remanded. Entitlement to an initial compensable rating for a left knee disability with shin splints is remanded. Entitlement to service connection for a right forearm disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a right wrist disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. Entitlement to specially adapted housing or special home adaptation is remanded. FINDINGS OF FACT 1. The Veteran has an acquired psychiatric disorder that is proximately due to her service-connected disabilities. 2. The Veteran’s bilateral hearing loss has not manifested as auditory thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz of 40 decibels or greater, auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz of 26 decibels or greater, or speech recognition scores using the Maryland CNC Test of less than 94 percent in either ear at any time during the period of the claim; thus, she has not had hearing loss in either ear for VA purposes during the period of the claim. 3. The Veteran has not been diagnosed with any breathing-related disability during the period of the claim. 4. Throughout the period of the claim, the Veteran’s lower back disability has been manifested by forward flexion of the thoracolumbar spine limited to 30 degrees or less; it has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. 5. The award of service connection for the Veteran’s lower back, bilateral hip, and bilateral knee disabilities was made effective June 19, 2014, the day following her separation from active service; this is the earliest allowable effective date pursuant to VA regulations. 6. The Veteran’s claim for service connection for tinnitus was first received by VA on August 24, 2015. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2017); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 3. The criteria for service connection for a breathing-related disability have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.385 (2017); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 4. The criteria for an initial disability rating higher than 40 percent for the Veteran’s lower back disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5242 (2017). 5. The criteria for an effective date earlier than June 19, 2014, for the award of service connection for lower back, bilateral hip, and bilateral knee disabilities, have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 6. The criteria for an effective date earlier than August 24, 2015, for the award of service connection for tinnitus, have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty in the United States Army from March 2014 to June 2014. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of January 2015, November 2015, and May 2018 rating decisions by Department of Veterans Affairs (VA) Regional Offices (ROs). The scope of a mental health claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Board refers to the Veteran’s mental health condition(s) broadly, as an acquired psychiatric disorder, herein. The record shows the Veteran has raised the issue of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. Accordingly, the Board has taken jurisdiction over this issue as part and parcel of the increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). General Legal Criteria Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2017). Disability Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321(a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis The Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to the Veteran’s claims. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s claims. Service connection for an acquired psychiatric disorder The record shows the Veteran has been diagnosed with an acquired psychiatric disorder. The Board observes that during service, the Veteran suffered injuries to her lower back and bilateral hips, to include bilateral hip stress fractures. As is further discussed below, the Veteran has been granted service connection for lower back, bilateral hip, and bilateral knee disabilities, among other conditions. In a January 2017 report, a private psychologist, Dr. H.G., indicated she had interviewed the Veteran and reviewed her claims file. Dr. H.G. diagnosed the Veteran with “depressive disorder due to another medical condition,” and noted the Veteran’s reports that her physical conditions, specifically her service-connected lower back, bilateral hip, and bilateral knee disabilities, impacted her mood. Specifically, the Veteran reported, in pertinent part, that she had low energy, low motivation, social isolation and withdrawal, dislike of crowds, and frustration that she had to depend on others for help with mobility. The Veteran reported these symptoms were not present before military service. Ultimately, Dr. H.G. opined that the Veteran’s lower back, bilateral hip, and bilateral knee disabilities, in addition to her tinnitus, were more likely than not causing her depressive disorder. In support of her opinion, Dr. H.G. stated there was a body of medical literature detailing the connection between medical issues like the Veteran’s and psychiatric disorders, such as depressive disorder. She stated that this literature demonstrated a causal relationship between medical and psychiatric difficulties. The Board observes that the January 2017 report includes a clear explanation for the Veteran’s psychiatric diagnosis and the reasons for Dr. H.G.’s conclusion that the psychiatric condition is causally related to the Veteran’s service-connected physical impairments. Upon a thorough review of the record, there is no medical evidence contradicting the January 2017 report by Dr. H.G. After careful consideration, the Board finds the evidence is at least in equipoise as to whether the Veteran’s acquired psychiatric disorder is proximately due to her service-connected disabilities. As such, granting of service connection for an acquired psychiatric disorder is warranted. Service connection for bilateral hearing loss At the outset, the Board notes that for purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (2017). The Board also notes that the U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Veteran was afforded a VA audiology examination in December 2014. Upon examination, puretone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 15 15 10 LEFT 10 10 15 15 5 Speech discrimination was 96 percent in the right ear and 94 percent in the left ear. The examiner indicated the Veteran had normal hearing in both ears. The Veteran was afforded an additional VA audiology examination in November 2015. Upon examination, puretone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 20 15 LEFT 20 20 20 15 5 Speech discrimination was 100 percent in the right ear and 100 percent in the left ear. The examiner indicated the Veteran had normal hearing in both ears. The Board observes that neither the December 2014 nor the November 2015 auditory thresholds detailed above meet the criteria for a hearing impairment disability under 38 C.F.R. § 3.385. The Board has thoroughly reviewed the record, and has found there is no medical evidence showing auditory thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz of 40 decibels or greater, auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz of 26 decibels or greater, or speech recognition scores using the Maryland CNC Test of less than 94 percent in either ear at any time during the period of the claim. Accordingly, although the Veteran may have some level of subjective hearing loss, the Board must conclude that the Veteran does not have a hearing impairment disability for the purposes of applying the laws administered by VA. Because there is no evidence of a hearing loss disability for VA purposes in either ear at any time during the period of the claim, the claim for service connection for bilateral hearing loss must be denied. In reaching its decision, the Board has duly considered the benefit-of-the-doubt doctrine, but has determined that a preponderance of the evidence weighs against the Veteran’s claim. As such, the doctrine is inapplicable and the claim must be denied. Service connection for a breathing-related disability The Board again notes that the U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Veteran filed a claim for service connection for “breathing problems” in July 2014. She was afforded a VA respiratory examination in December 2014. At the top of the examination report, the VA examiner indicated the Veteran had never been diagnosed with a respiratory condition. The examiner noted the Veteran’s reports that since her pain in her low back and pelvis started in May 2014, she had been reluctant in taking deep breaths as she could feel the pain in her lower lungs. She reported that very rarely she would cough and when she did she felt the pain in her lower back and pelvis was worse. She also stated she had a sensation of not having enough breaths and that she could not breathe deep. She denied, however, ever having any problems with her pulmonary systems. A review of the record does not show the Veteran has ever been diagnosed with any respiratory disability or disability affecting her breathing. Thus, although the Veteran’s reports of a subjective feeling of increased musculoskeletal pain when breathing or coughing are credible, it does not appear she has been diagnosed with any condition involving her pulmonary or respiratory systems. Thus, due to the absence of any diagnosis of a breathing-related disability during the period of the claim, the Board has determined the Veteran’s claim for service connection must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Lower back disability rating The Veteran’s lower back disability is rated under 38 C.F.R. § 4.71a, DC 5242, which utilizes the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula, in pertinent part, a 40 percent rating is warranted if forward flexion of the thoracolumbar spine is limited to 30 degrees or less; or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent evaluation is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, DCs 5235-5242 (2017). In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 (2017) concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 (2017) concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 (2017) concerning the effects of the disability on the Veteran’s ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran was afforded a VA examination in December 2014. Upon examination, it was noted that forward flexion of the thoracolumbar spine was limited to 15 degrees. The examiner indicated, however, that the Veteran did not have ankylosis of the spine. Upon a careful review of the foregoing, the Board finds the RO’s assignment of a 40 percent initial rating for the Veteran’s lower back disability is justified by the December 2014 VA examination findings. However, upon careful review of the entire record, there is no evidence the Veteran has had favorable or unfavorable ankylosis of the thoracolumbar spine or the entire spine at any time during the period of the claim. Accordingly, the Board finds a rating higher than 40 percent for the Veteran’s lower back disability is not warranted at any time during the period of the claim. The Board briefly notes that in the recent case of Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 4.59 requires that all VA examinations related to a joint disability must include testing for pain on both active and passive motion, in weight-bearing and non-weight bearing, and, if possible, with the range of motion measurements of the opposite, undamaged joint. In this regard, the Board notes the VA examination report summarized above did not indicate range of motion testing was performed on active and passive motion, as well as with and without weight-bearing. However, as noted above, a rating higher than 40 percent for the Veteran’s lower back disability would be warranted only upon a finding of ankylosis. Thus, the criteria for a rating higher than 40 percent could not be satisfied by additional range of motion testing results. As such, the Board has determined a remand for an additional VA examination in compliance with Correia is not required in this case. Earlier effective dates Generally, the effective date of an award shall be the day following separation from active service or the date entitlement arose if a claim is received within 1 year after separation from service; if a claim is received more than 1 year following separation, the effective date will be the date of receipt of a claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400(b)(2)(i) (2017). The effective date “shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefore.” 38 U.S.C. § 5110 (a) (2012). The record shows that the Veteran called VA on July 2, 2014, and notified a VA employee that she intended to apply for benefits. On a VA form received by VA on July 14, 2014, the Veteran filed claims for service connection, in pertinent part, for disabilities of the lower back, bilateral hips, and bilateral knees. In a January 2015 rating decision, service connection was granted for lower back, bilateral hip, and bilateral knee disabilities. The awards of service connection were all made effective June 19, 2014, the day after the Veteran’s separation from active service. Based on the foregoing, the date following separation from service is the earliest allowable effective date for an award of benefits. The Veteran has not contended she filed any claim for benefits prior to her separation from service, and has not otherwise put forth any particular argument in support of her claim for earlier effective dates for the award of service connection for lower back, bilateral hip, and bilateral knee disabilities. The record shows the Veteran filed a claim for service connection for tinnitus, which was received by VA on August 24, 2015. The claim was granted in a November 2015 rating decision, and the award of service connection was made effective on August 24, 2015. The claim was filed more than one year after the Veteran’s separation from active service on June 18, 2014. A thorough review of the record reveals nothing which could be construed as a formal or informal claim for service connection for tinnitus dated prior to August 24, 2015. The Veteran has not contended she filed any such claim prior to August 24, 2015, and she has not put forth any particular argument in support of her claim for an earlier effective date for the award of service connection for tinnitus. Based on the foregoing, the Board finds a preponderance of the evidence weighs against the Veteran’s claims for earlier effective dates for the awards of service connection for a lower back disability, a bilateral hip disability, a bilateral knee disability, and tinnitus. REMAND The Board finds additional development is required before the Veteran’s remaining claims are decided. Disability ratings for bilateral hip and bilateral knee disabilities As noted above, in the recent case of Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 4.59 requires that all VA examinations related to a joint disability must include testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with the range of motion measurements of the opposite undamaged joint. The Veteran was afforded VA hip and knee examinations in December 2014. The examination reports show that although the examiner conducted range of motion testing, the testing was not performed in both passive and active motion, as well as in weight-bearing and non-weight-bearing. For this reason, the Board finds a remand is required for additional examinations to assess the severity of the Veteran’s bilateral hip and knee disabilities in compliance with Correia. The Board also notes the Court recently held that the mere lack of an opportunity for a VA examiner to observe a flare-up of a service-connected condition is an insufficient basis for not estimating the flare-up’s functional effects. Sharp v. Shulkin, 29 Vet. App. 26 (2017). As such, the VA examiner(s) will be instructed to perform the examinations on remand in compliance with Sharp. Service connection for right shoulder, forearm, and wrist disabilities The Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran was afforded a VA examination in December 2014. The examiner diagnosed strains of the right shoulder, elbow, and wrist. He noted the Veteran’s reports that she had begun to experience right shoulder, forearm, and wrist pain during service. The Veteran attributed her right wrist pain to having to hold and fire heavy weapons. To date, no VA opinion has been obtained regarding the etiology of the Veteran’s right upper extremity disabilities. Under these circumstances, the Board finds the low threshold provided in McLendon has been satisfied, and that a remand is warranted for VA opinions addressing the Veteran’s claims. TDIU In a February 2017 correspondence, with supporting medical evidence attached, the Veteran’s representative raised the issue of entitlement to a TDIU. The Board observes, however, that no VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, has been filed in this case. As such, the Veteran’s work history and current employment status are unclear from the record. In this regard, the Board notes in a January 2017 report, it was noted the Veteran was employed at least as recently as October 2016. For this reason, the Board finds a remand is warranted to obtain a completed VA Form 21-8940 from the Veteran. In addition, the Board finds the Veteran’s claim of entitlement to a TDIU is inextricably intertwined with the increased rating and service connection claims being remanded. Thus, the claim for a TDIU must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Specially adapted housing/special home adaptation In a May 2018 rating decision, the RO denied the Veteran’s claims of entitlement to specially adapted housing and entitlement to special home adaptation. In June 2018, the Veteran’s representative filed a notice of disagreement (NOD) with the decision. To date, the RO has not issued a statement of the case (SOC) addressing these issues. Because the Veteran’s NOD placed the issues in appellate status, the claims must be remanded for issuance of an SOC, if the claims cannot be granted. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matter is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Solicit a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, from the Veteran, detailing her work history and current employment status. 3. Afford the Veteran a VA examination to determine the current severity of her service-connected bilateral hip disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. The examiner is directed to perform range of motion testing to determine the extent of limitation of motion due to pain on active motion and passive motion, as well as with weight-bearing and without weight-bearing. If the examiner is unable to conduct the required testing or concludes the required testing is not necessary in this case, he or she should clearly explain why this is so. The examiner should further discuss additional functional limitation of the right and left hips with repeated movement over time and upon flare-ups. Any such additional limitation of motion should be expressed in additional degrees of lost motion. The examiner must attempt to provide an estimate, even in the absence of an opportunity to observe any reported flare-up. The estimate may be based on the Veteran’s reports of limitation during such flares. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Afford the Veteran a VA examination to determine the current severity of her service-connected bilateral knee disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. The examiner is directed to perform range of motion testing to determine the extent of limitation of motion due to pain on active motion and passive motion, as well as with weight-bearing and without weight-bearing. If the examiner is unable to conduct the required testing or concludes the required testing is not necessary in this case, he or she should clearly explain why this is so. The examiner should further discuss additional functional limitation of the right and left knees with repeated movement over time and upon flare-ups. Any such additional limitation of motion should be expressed in additional degrees of lost motion. The examiner must attempt to provide an estimate, even in the absence of an opportunity to observe any reported flare-up. The estimate may be based on the Veteran’s reports of limitation during such flares. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Afford the Veteran a VA examination to determine the nature and etiology of her right forearm, shoulder, and wrist disabilities. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all right forearm, right shoulder, and right wrist disabilities present during the period of the claim. Then, with regard to each identified right forearm, shoulder, and wrist disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability had its onset during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinions, the examiner should note the Veteran’s lay statements to the effect that she began experiencing right forearm, shoulder, and wrist pain and discomfort during service, to include due to having to hold and fire heavy weapons. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Issue a statement of the case addressing the issue of entitlement to specially adapted housing and entitlement to special home adaptation, if the claims cannot be granted. Thereafter, the Veteran should be given an opportunity to perfect an appeal by submitting a timely substantive appeal. The Veteran should be advised that the claims file will not be returned to the Board for appellate consideration of this issue unless she perfects an appeal. 7. Undertake any other development determined to be warranted. 8. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs