Citation Nr: 18147542
Decision Date: 11/06/18	Archive Date: 11/05/18

DOCKET NO. 17-55 014
DATE:	November 6, 2018
ORDER
Service connection for a left shoulder disability is granted.
Service connection for photophobia is granted.
REMANDED
Service connection for a thoracolumbar spine disability is remanded.
Service connection for a right shoulder disability is remanded.
Service connection for a bilateral hand disability is remanded.
Service connection for a bilateral knee disability is remanded.
Service connection for a bilateral ankle disability is remanded.
Service connection for hearing loss is remanded.
Service connection for eczema is remanded.
Entitlement to an increased initial evaluation greater than 20 percent for cervical spine intervertebral disc syndrome (IVDS) is remanded.
Entitlement to an initial compensable evaluation for gastroesophageal reflux disease (GERD) with hiatal hernia is remanded.
Entitlement to an increased initial evaluation for posttraumatic stress disorder (PTSD) (formerly rated as adjustment disorder) greater than 30 percent from January 1, 2015 and greater than 50 percent from February 2, 2018, is remanded.
Entitlement to a total disability rating for individual unemployability (TDIU) is remanded.
FINDINGS OF FACT
1. The Veteran’s left shoulder disability began during active service.
2. The Veteran’s photophobia began during active service. 
CONCLUSIONS OF LAW
1. The criteria for service connection for a left shoulder disability are met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).
2.  The criteria for service connection for a photophobia are met.  38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran honorably served United States Marine Corps on active duty from September 1997 to December 2014. This matter is before the Board of Veterans’ Appeals (Board) on appeal from May and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Board is grateful for this Veteran’s long and honorable service to this nation. 
The Veteran submitted two substantive appeals to the statements of the case (SOC) issued in August 2017. On one, the Veteran indicated that he was confining his appeal only to the issues of service connection for a bilateral hand disability, bilateral shoulder disability, bilateral knee disability, bilateral ankle disability, and a thoracolumbar spine disability; however, on the other substantive appeal, he indicated that he wanted to appeal all of the issues on the statement of the case. See Veteran’s Appeals to the Board (VA Form 9). In the interest of providing the Veteran with the broadest and most sympathetic review, the Board finds that the substantive appeal requesting appeal of all of the issues on the statement of the case applies to all statements of the case during the appropriate appellate time period. See 38 C.F.R. § 20.202 (“The Board will construe such arguments in a liberal manner for purposes of determining whether they raise issues on appeal.”). 
The record reflects that the Veteran’s service-connected disabilities may have prevented him from working during the appeal period. See April 2018 Board hearing. Because a TDIU rating is inherent in any claim for an increased rating, see Rice v. Shinseki, 22 Vet. App. 447 (2009), it has been added as an issue.
Service Connection
Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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).
When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
1. Service connection for a left shoulder disability. 
The Veteran has treated for left shoulder pain and shown such positive signs as winging of the scapula, restricted range of motion, and tenderness to palpation on the left scapula, trapezius, and rhomboid, beginning in service and continuing into the appellate period. See, e.g., July 2013 Management Clinic Notes; February 2014 Pain Management Notes; July 2016 Pain Management Notes. On x-ray, the Veteran showed asymmetrical width in the acromioclavicular (AC) joint and possible acromioclavicular separation. See September 2014 X-Ray. Although it is not clear from the record exactly which diagnoses apply to the Veteran’s left shoulder, see, e.g., December 2002 In-Service Treatment Record (diagnosing left rhomboid strain/spasm); July 2016 Pain Management Notes (diagnosing “myalgias”), it is clear from the above that the Veteran experiences pain and functional impairment due to his left shoulder, which qualifies as a disability within the meaning of the law. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018).  
The Board acknowledges that a VA examiner opined that the x-ray imaging showed no clinically significant findings and the Veteran does not have and has never had a shoulder or arm condition. See October 2014 VA Examination (Shoulders and Arms) by R.S., D.O. However, the Board cannot accord this opinion any probative weight because it did not consider the relevant evidence, including the medical evidence leading up to the examination and which reflects treatment for left shoulder pain, and does not explain why asymmetrical AC joint width and possible separation are not clinically significant. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (holding that an examination must take into account an accurate history to be adequate); Bloom v. West, 12 Vet. App. 185, 187 (1999) (holding that the probative value of an opinion depends in part upon the extent it reflects “clinical data or other rationale to support the opinion”). 
Accordingly, because the preponderance of the evidence supports a finding that the Veteran had a left shoulder disability that began during service and persists into the period on appeal, the claim for service connection for a left shoulder disability must be granted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
2. Service connection for photophobia. 
On examination, the Veteran was diagnosed with photophobia and the Veteran has stated that he has had photophobia since he injured his eye during active service in 1999. See September 2014 VA Examination (Eyes) by C.L., O.D.; May 2016 Veteran’s Notice of Disagreement (VA Form 21-0958); see also January 1999 In-Service Treatment Records (reflecting photophobia concurrent with a foreign body in the eye and a corneal rust ring). The Board finds the Veteran’s statements highly probative because he is competent to report his symptom of light sensitivity, when it began, and the persistence of the symptom. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds he is credible because of his consistency with the medical record, including the fact that he reported eye sensitivity on his retirement examination. See August 2014 Retirement Report of Medical History. 
Accordingly, because the preponderance of the evidence supports a finding that the Veteran incurred photophobia in service and it persists into the period on appeal, the claim for service connection for photophobia must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).

REASONS FOR REMAND
1. Service connection for a thoracolumbar spine disability is remanded.
The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that adequately addresses the facts and circumstances presented by the Veteran’s case. Primarily, the VA examiner opined that the Veteran does not have a thoracolumbar spine disability. See October 2014 VA Examination (Thoracolumbar Spine) by R.S., D.O. However, this opinion did not address all of the relevant evidence, including the medical evidence leading up to the examination and which reflects that the Veteran has a thoracic syrinx, congenital fusion of the T3-T4 vertebrae, and s-shaped curvature of the thoracic spine. See May 2013 Radiology Report; August 2014 In-Service Treatment Note; July 2016 Pain Management Notes; see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (holding that an examination must take into account an accurate history to be adequate); Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that opinions based on inaccurate factual premises are entitled to no probative weight). Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, a remand is required to obtain an adequate examination. 
Additionally, the record reflects that the Veteran has continuing non-VA treatment and may have relevant medical records not associated with the file. Because this issue must already be remanded, additional development to obtain relevant medical records should be attempted. 


2. The issues of service connection for a right shoulder disability, a bilateral hand disability, a bilateral knee disability and a bilateral ankle disability are remanded.
The VA examiner opined that the Veteran has no pathology to render a diagnosis for the Veteran’s right shoulder disability, bilateral hand disability, bilateral knee disability, and bilateral ankle disability. See October 2014 VA Examination (Shoulder and Arms) by R.S., D.O.; October 2014 VA Examination (Hand and Finger) by R.S., D.O.; October 2014 VA Examination (Knee and Lower Leg) by R.S., D.O.; October 2014 VA Examination (Ankle) by R.S., D.O. However, since the examination, the Court of Appeals for the Federal Circuit has clarified that 
“pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability” in the event that there is accompanying functional impairment. Saunders v. Wilkie, 886 F.3d 1356, 1363, 1368-1369 (Fed. Cir. 2018). Accordingly, a remand is required to obtain an examination to determine whether the Veteran’s pain symptoms result in functional impairment. 
There is additionally an issue that the opinion included that there was no pathology to render a diagnosis for the Veteran’s hands or knees; however, the diagnostic imaging reports reflect potential abnormalities in the right fourth digit and in the bilateral knees, but there was no explanation for how the examiner came to the conclusion that there were only clinically insignificant findings noted. See September 2014 Right Hand X-ray (noting stress-induced elongation of the distal phalanx of the fourth digit); September 2014 Right and Left Knee X-rays (noting asymmetric joint spaces); October 2014 VA Examination (Hand and Finger) by R.S., D.O.; October 2014 VA Examination (Knee and Lower Leg) by R.S., D.O.; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (holding that the probative value of an opinion depends in part upon the extent it reflects “clinical data or other rationale to support the opinion”). Accordingly, an opinion that addresses these findings is required.


3. Service connection for hearing loss is remanded.
With hearing loss claims, VA may only find hearing loss to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. The Veteran did not have a hearing loss disability for VA purposes at the time of the VA examination. See October 2014 VA Examination (Hearing Loss and Tinnitus) by M.H. Jr., Ph.D., F-AAA. However, treatment records reflect that he reports that his hearing loss has worsened. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Accordingly, a remand is required to afford the Veteran a new VA examination to determine whether he has a current hearing loss disability as defined for VA purposes.
4. Service connection for eczema is remanded.
The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that adequately addresses the Veteran’s statements that he was diagnosed with eczema in service and that episodes or symptoms come and go. May 2016 Veteran’s Notice of Disagreement (21-0958); see Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history). Notably, the examiner’s May 2015 addendum response indicates that he declined to diagnose the Veteran with eczema because it was not present on examination. See May 2015 Addendum Opinion by R.S., D.O. Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, a remand is required to obtain an examination and opinion that addresses the Veteran’s statements. 
5. Entitlement to an increased initial evaluation greater than 20 percent for cervical spine intervertebral disc syndrome is remanded.
The Veteran reported in his notice of disagreement that he has several months of incapacitating episodes and that he often cannot turn his head. See May 2016 Veteran’s Notice of Disagreement (VA Form 21-0958). This indicates that either the Veteran’s neck condition has materially changed and a remand is required, see Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007), or that the Veteran has flare-ups that were not addressed in the examination report and a remand is required. See Sharp v. Shulkin, 29 Vet. App. 26 (2017).   
VA examinations must include joint testing on both active and passive motion, and in weight-bearing and nonweight-bearing circumstances. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, estimated ranges of motion should be provided during flare-ups, if feasible, even if the Veteran is not experiencing one during the examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, the VA cervical spine examination of record does not fully comport with these requirements. See March 2013 VA examinations. Thus, remand is necessary for a new VA cervical spine examination.
6. Entitlement to an initial compensable evaluation for GERD with hiatal hernia is remanded.
The Veteran reported in his notice of disagreement that he had GERD and hiatal hernia symptoms of regurgitation, difficulty swallowing, heartburn, and arm and chest pain, see May 2016 Veteran’s Notice of Disagreement (VA Form 21-0958), but these symptoms were not included in the Veteran’s VA examination. See October 2014 VA Examination (Esophageal Conditions) by R.S., D.O.; see also June 2016 Private Treatment Note (reporting that the medication works to control GERD symptoms perfectly). This indicates that the Veteran’s examination took into account the Veteran’s symptoms while considering the effect of his medication, which is not appropriate in this case. The Board is prohibited from considering the ameliorative effects of medication when, as here, the effects are not specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Accordingly, a remand is required to obtain an examination that includes consideration of the Veteran’s symptoms without the effect of medication. 
7. Entitlement to an increased initial evaluation for posttraumatic stress disorder (PTSD) (formerly rated as adjustment disorder) greater than 30 percent from January 1, 2015 and greater than 50 percent from February 2, 2018, is remanded.
The relevant VA examinations include diagnoses of adjustment disorder and PTSD. See September 2014 VA Examination (PTSD) by E.R., M.D.; April 2018 VA Examination (PTSD) by M.C., Psy.D. However, the Veteran has also been diagnosed by his private provider with major depressive disorder and has endorsed symptoms of occupational and social impairment, which may or may not be related to service-connected PTSD or nonservice-connected major depressive disorder. See, e.g., December 2016 Private Psychiatric Treatment (noting that the Veteran eats and spends most of his time away from his family); May 2017 Psychological Evaluation Report (noting that the Veteran wants to find a job in which he is left alone and in which he is in control). It is not clear whether the Veteran has symptoms and impairment that may be exclusively attributed to nonservice-connected psychiatric diagnoses, which is a critical fact that must be determined prior to adjudicating his claim for increase. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (barring the Board is from differentiating between symptoms attributable to PTSD and those associated with nonservice-connected mental health disorders absent clinical evidence clearly showing such distinction). Accordingly, a remand to obtain clarification is required. 
8. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded.
The matter of entitlement to TDIU is inextricably intertwined with the Veteran’s other remanded issues; accordingly, it must be remanded as well.


The matters are REMANDED for the following action:
1. Send a letter to the Veteran requesting that he identify any relevant outstanding private treatment records and any other relevant evidence pertaining to his claim of entitlement to an increased rating for service-connected cervical IVDS, PTSD, or GERD, or for service connection for bilateral ankle, bilateral knee, bilateral hand, right shoulder, thoracolumbar spine, eczema, and hearing loss disabilities. He should be invited to submit this evidence himself or to request that VA to obtain it on his behalf. Authorized release forms (VA Form 21-4142) should be provided for this purpose.
If the Veteran properly fills out and returns any authorized release forms for private records identified by him, reasonable efforts should be made to obtain such records and associate them with the claims file. At least two such efforts should be made unless it is clear from the private provider’s response to the first request that a second effort would be futile.
If attempts to obtain any records identified by the Veteran are not successful, he MUST be notified of this fact and all efforts to obtain them must be documented and associated with the claims file.
2. The AOJ should provide the Veteran appropriate notice of VA’s duties to notify and assist regarding how to substantiate a claim for entitlement to TDIU, to include providing him a VA Form 21-8940. The Veteran should assist in the matter by providing the requested information.
3.  After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s bilateral ankle, bilateral knee, bilateral hand, and right shoulder disabilities. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Based on the factual evidence of record and the examinations, the examiner must provide an opinion that responds to the following:
(a.) Please identify the Veteran’s ankle, knee, hand and right shoulder conditions by diagnosis(es) for each of the conditions. 
(b.) For each claimed body part, please state whether the Veteran has pain with functional impairment that is not attributable to any diagnosed disability.  [The Board notes that the Veterans Court recently held that pain, even without a diagnosis, does count as a disability for VA compensation purposes if the pain causes functional impairment].
(c.) For EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current conditions were incurred in active military service? 
The examiner’s attention is drawn to the following records (the following is a brief factual background and not intended to be a substitute for your review of the Veteran’s claims folder):
* March 1997 entrance examination reflecting no abnormalities.
*September 1998 left ankle sprain with edema.
*April 1999 right hand, fourth digit contusion.
*December 1999 left hand laceration to the fifth digit
*June 2001 right ankle sprain.
*July 2002 light duty for a right foot injury with temporary parasthesia.
*January 2003 right ankle sprain hurting since December 2002, prescribed physical therapy. 
*December 2010 reporting bilateral knee pain. 
*September 2013 reporting bilateral hand numbness after driving.
*August 2014 reporting bilateral knee pain, ankle pain for years with inability to walk more than 15-20 minutes without pain. 
*September 2014 retirement examination reporting ankle pain when walking, jumping, running, or when any weight is on them; painful knees, knuckles, shoulders, and wrists; knees have pain, clicking, and give out. 
*September 2014 right hand x-ray showing stress-induced elongation of the distal phalanx of the fourth digit.	
*September 2014 bilateral knee x-rays showing asymmetrical joint spaces.
In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence.
Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested.
If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training).
If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided.
4. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s thoracolumbar condition(s), including congenital T3-T4 fusion, thoracic syrinx, and s-shaped thoracic spine. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following:
(a.) Please identify the Veteran’s thoracolumbar conditions by diagnosis(es). 
(b.) For EACH of the diagnosed thoracolumbar conditions, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current thoracolumbar condition(s) was incurred in active military service?
(c.) Is the Veteran’s T3-T4 fusion the result of a congenital defect, a congenital disease, or an acquired disorder? For purposes of VA compensation, a congenital “defect” is defined as a condition that is more or less stationary in nature, whereas a congenital “disease” is defined as a condition capable of improving or deteriorating (please apply this legal definition regardless of whether the medical community’s terminology or conception includes it as a “defect”). 
(d.) If it is determined that the Veteran has a congenital defect, is it at least as likely as not (a 50 percent or greater probability) that this defect was subject to a superimposed disease as a result of service? If the answer is “Yes,” please describe the resultant disability.
(e.) If it is determined that the Veteran has a congenital disease, is there clear and unmistakable (obvious, manifest, and undebatable) evidence that any congenital disease WAS NOT aggravated (i.e., permanently worsened) during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase was due to natural progress? 
(f.)  Is it at least as likely as not (defined as a 50% or better probability) that any thoracolumbar condition was proximately caused by or aggravated by Veteran’s service-connected cervical spine IVDS?
The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression.
In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence.
Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested.
If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training).
If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 
5. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine whether the Veteran has a hearing loss disability pursuant to VA regulations.
All necessary tests, including an audiological evaluation, must be conducted. 
Thereafter, if the Veteran has a hearing loss disability pursuant to VA regulations, the examiner must opine as to whether it is at least as likely as not that the Veteran’s hearing loss is related to or had its onset in service. 
6. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s eczema or other condition(s). The examiner must review the entire record in conjunction with the examination and note such review was conducted. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following:
(a.) Please take a detailed history of the Veteran’s skin condition(s), to include symptoms, onset of symptoms, treatment, and diagnoses.
(b.) Please identify the Veteran’s skin condition(s) by diagnosis(es). Please provide a complete explanation (rationale) if the diagnosis of eczema is not given.

For our purposes, a “current” disability includes any disability that occurred since filing his claim; it does not need to be active during the examination to qualify as a current disability.
(c.) For EACH* of the diagnosed skin conditions(s), is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current skin condition(s) was incurred in active military service?
*Do not provide an opinion on xanthelasma. This condition is service-connected.
In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence.
Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested.
If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training).
If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided.
7. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected PTSD and provide an opinion on when the severity of such symptoms began based on review of the medical record and the examination. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria.  The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms.  

To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to PTSD alone. If it is not possible to isolate the symptoms of PTSD alone, please note that. Please note that the Veteran has also been diagnosed with major depressive disorder, which is not presently service-connected.

In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. 
8. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected cervical spine IVDS. The examiner must review the entire record in conjunction with the examination and note such review was conducted. 

Range of motion measurements must be included for active and passive motion, and weight-bearing and non-weight-bearing circumstances. If pain is noted, the point in the range of motion at which pain starts should be clearly noted.
If possible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). A rationale based on the fact that the Veteran is not having a flare-up at the time of the examination will not be adequate as a matter of law. 
Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested.
In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. 
9. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected cervical GERD with hiatal hernia. The examiner must review the entire record in conjunction with the examination and note such review was conducted. 
The examiner should provide a full description of the disability and report all signs and symptoms associated with the Veteran’s disability, specifically WITHOUT consideration of the effects of medication. The examiner should use lay observations specifically elicited from the Veteran. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). A rationale based on the fact that the Veteran is currently medicated will not be adequate. 
[CONTINUED ON THE NEXT PAGE] 
In forming any opinions or conclusions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. 

 
VICTORIA MOSHIASHWILI
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	S. Lambert, Associate Counsel