Citation Nr: 18150097 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-38 561 DATE: November 14, 2018 ORDER Entitlement to a compensable rating for service-connected scar, residuals radiculopathy, discectomy lumber spine is denied. Subject to the law and regulations governing payment of monetary benefits, a 20 percent rating for the Veteran’s radiculopathy, right lower extremity is granted from September 1, 2016. Subject to the law and regulations governing payment of monetary benefits, a 40 percent rating for the Veteran’s radiculopathy, left lower extremity is granted from September 1, 2016. Entitlement to a rating in excess of 10 percent for radiculopathy, right lower extremity prior to September 1, 2016 is denied. Entitlement to a rating in excess of 20 percent for radiculopathy, left lower extremity prior to September 1, 2016 is denied. Subject to the law and regulations governing payment of monetary benefits, a 40 percent rating for the Veteran’s degenerative disc disease, lumbar spine with residuals, discectomy, L4-L5 is granted effective May 1, 2013. Entitlement to a rating in excess of 40 percent for degenerative disc disease, lumber spine with residuals, discectomy, L4-L5 is denied for the appeal period. REMANDED Entitlement to service connection for right hip strain, to include as secondary to service-connected degenerative disc disease (DDD), lumbar spine with residuals, discectomy, L4-L5 is remanded. Entitlement to service connection for left hip strain, to include as secondary to service-connected degenerative disc disease (DDD), lumbar spine with residuals, discectomy, L4-L5 is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected degenerative disc disease, lumbar spine residuals, discectomy, L4-L5 is remanded. FINDING OF FACT 1. The Veteran’s scar, residuals radiculopathy, discectomy lumber spine, is not manifested by pain or tenderness and does not cause functional impairment. 2. The Veteran’s neurologic impairment of the right lower extremity results in disability analogous to moderate incomplete paralysis of the sciatic nerve right from September 1, 2016. 3. The Veteran’s neurologic impairment of the left lower extremity results in disability analogous to moderately severe incomplete paralysis of the sciatic nerve right from September 1, 2016. 4. The Veteran’s radiculopathy, right lower extremity was productive of no more than in disability analogous to mild incomplete paralysis of the sciatic nerve prior to September 1, 2016. 5. The Veteran’s radiculopathy, left lower extremity was productive of no more than disability analogous to moderate incomplete paralysis of the sciatic nerve prior to September 1, 2016. 6. The evidence of record reflects the Veteran’s service-connected degenerative disc disease more nearly approximated limitation of flexion of the thoracolumbar spine to 30 degrees or less when accounting for additional pain during flare ups and the ameliorative effects of medication, for the period prior to September 1, 2016. 7. The evidence of record does not reflect the Veteran’s service-connected degenerative disc disease has been manifested by ankylosis, associated neurologic impairment, or incapacitating episodes as defined by VA regulations at any point during the appeal period. CONCLUSION OF LAW 1. The criteria for a compensable rating for scar, residuals radiculopathy, discectomy lumber spine, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2017). 2. The criteria for a 20 percent disability rating for service-connected radiculopathy, right lower extremity, from September 1, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.123, 4.124, 4.124a. Diagnostic Code 8620 (2017). 3. The criteria for a 40 percent disability rating for service-connected radiculopathy, left lower extremity, September 1, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.123, 4.124, 4.124a. Diagnostic Code 8620 (2017). 4. The criteria for a rating in excess of 10 percent for service-connected radiculopathy, right lower extremity, prior to September 1, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.123, 4.124, 4.124a. Diagnostic Code 8620 (2017). 5. The criteria for a rating in excess of 20 percent for service-connected radiculopathy, left lower extremity, prior to September 1, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.123, 4.124, 4.124a. Diagnostic Code 8620 (2017). 6. The criteria for a 40 percent rating for service-connected degenerative disc disease, prior to September 1, 2016, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 7. The criteria for a rating in excess of 40 percent for service-connected degenerative disc disease are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from August 1979 to September 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to a compensable rating for service-connected scar, residuals radiculopathy, discectomy lumber spine. The Veteran seeks a compensable rating for a residual scar from a surgical discectomy L4-L5. The Veteran’s noncompensable rating was assigned under 38 C.F.R. § 4.118, Diagnostic Code 7805, which rates scars based on the limitation of function of the part affected. The evidence establishes that a compensable rating for the bilateral leg scars, status post lacerations, is not warranted at any time during the appeal. Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. Diagnostic Code 7802 provides for a 10 percent disability evaluation for a scar not of the head, face, or neck, that is superficial and nonlinear and which covers an area of at least 144 square inches (929 sq. cm.) or more. A superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7804 provides for a 10 percent evaluation for one or two scars that are unstable or painful. A 20 percent disability evaluation is assigned where there are three or four scars that are unstable or painful. An unstable scar is one where there is frequent loss of skin covering over the scar. If one or more scars are both unstable and painful 10 percent is added to the evaluation. Pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of Diagnostic Codes 7801-7804. The August 2015 physical residual functional capacity questionnaire, lists scar pain as one of his symptoms; however, that questionnaire and the subsequent September 2016 VA examination do not establish that the criteria for a compensable rating for a residual scar from a surgical discectomy L4-L5 are met. The September 2016 VA examiner reports the Veteran has a linear 2.5 cm scar. The examiner notes the scar is not painful or unstable. There are no scars due to burns or scars with frequent loss of covering of skin over the scar. The examiner indicated, the Veteran’s scar does not impact his ability to work. The examiner stated, the Veteran’s scar is well healed, with no restrictions, and not disabling. The Board finds this opinion to be persuasive and of the greatest probative value. As the competent and credible evidence of record is against a compensable rating for compensable rating for service-connected scar, residuals radiculopathy, discectomy lumber spine; there is no doubt to be resolved and the claim must be denied. Increased Rating Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 ; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found a practice known as “staged” ratings. More recently, the Court held that “staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104 (a). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). Entitlement to an increased rating for radiculopathy, right lower and left lower extremity. The Veteran asserts that his radiculopathy of the right lower extremity and left lower extremity warrant higher ratings than their current disability ratings. The Veteran’s radiculopathy, right lower extremity is currently rated at 10 percent disabling and radiculopathy, left lower extremity is rated at 20 percent disabling. Sciatic nerve neurological manifestations are rated under Diagnostic Code 8520, 8620, or 8720 as, respectively, paralysis, neuritis or neuralgia of the sciatic nerve. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Incomplete paralysis of the sciatic nerve warrants a 60 percent evaluation if it is severe with marked muscular dystrophy, a 40 percent evaluation if it is moderately severe, a 20 percent evaluation if it is moderate or a 10 percent evaluation if it is mild. The preface to 38 C.F.R. § 4.124a states that when the involvement is wholly sensory, the rating should be for the mild, or at the most, the moderate degree. In addition, the preface states that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. The Board acknowledges that the terms “mild,” “moderate,” and “severe” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “moderate” or “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes only, that the definitions for “mild” includes not very severe. WEBSTER’S II NEW COLLEGE DICTIONARY at 694 (1995). The Board also notes that a synonym for “mild” is “slight” and definitions for “slight” includes small in size, degree, or amount. Id. at 1038. The definitions for “moderate” includes of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions for “severe” includes extremely intense. Id. at 1012. It is also noted that the term “moderately severe” includes impairment that is considered more than “moderate” but not to the extent as to be considered “severe.” In this case, the Board finds that the Veteran’s radiculopathy, right lower extremity is demonstrated by moderate incomplete paralysis of the sciatic nerve and the Veteran’s radiculopathy, left lower extremity is manifested with moderately severe incomplete paralysis of the sciatic nerve from the September 2016 VA examination. The Veteran’s September 2016 VA examiner found the severity of the Veteran’s radiculopathy of the right side to be moderate and the left side to be severe. The examiner did not indicate the Veteran has marked muscular atrophy in his right lower extremity or left lower extremity. The examiner noted mild intermittent pain of the lower right extremity; however, he did not indicate constant pain, paresthesias and/or dysesthesias or numbness of the right lower extremity. The examiner indicates the Veteran has severe constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias and severe numbness of the left lower extremity. The Board finds that the medical evidence of record suggests moderate incomplete impairment of the sciatic nerve for the Veteran’s radiculopathy, right lower extremity and moderately severe impairment of the sciatic nerve for the Veteran’s radiculopathy, left lower extremity from September 1, 2016. In view of the foregoing, the Board does not find that the competent and credible evidence of record does not demonstrate that the Veteran’s radiculopathy, right lower or left lower extremity has resulted in complete paralysis or severe, incomplete paralysis with marked muscular atrophy. Additionally, there is nothing in the record to indicate the Veteran’s radiculopathy, right lower extremity has resulted in moderate incomplete paralysis. Therefore, a 20 percent rating is warranted for the right lower extremity and a 40 percent disability rating is warranted for the left lower extremity from September 1, 2016. Prior to September 1, 2016 The Veteran’s October 2015 neurosurgery note, indicates the Veteran has constant radiculopathy in his bilateral lower extremities which the Veteran rated as mild on the right and moderate on the left. The Veteran further indicated that the radiculopathy of his left lower extremity can be severe at times. The September 2014 VA examiner, reported the severity of the Veteran’s radiculopathy, right lower extremity as mild and radiculopathy, left lower extremity as moderate. The examiner indicated the Veteran’s right lower extremity had mild constant pain, no intermittent pain and mild numbness and paresthesias and/or dysesthesias. The VA examiner recorded the Veteran’s left lower extremity as having moderate constant pain, no intermittent pain, moderate paresthesias and/or dysesthesias and moderate numbness. The Board finds that the medical evidence of record suggests mild incomplete impairment of the sciatic nerve for the Veteran’s radiculopathy, right lower extremity and moderate impairment of the sciatic nerve for the Veteran’s radiculopathy, left lower extremity prior to September 1, 2016. Therefore, a rating in excess of 10 percent for the right lower extremity and in excess of 20 percent for the left lower extremity is not warranted for the period prior to September 1, 2016. Increased Rating Degenerative Disc Disease Prior to September 1, 2016 The Veteran is seeking an increased rating for his service-connected degenerative disc disease prior to September 1, 2016. The Veteran’s service-connected back disability is currently rated at 20 percent prior September 1, 2016 and 40 percent disabling from September 1, 2016. Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Additionally, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran seeks a higher rating for his low back disability, currently rated as 20 percent disabling pursuant to DC 5242. This diagnostic code directs VA to rate the Veteran under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, DC 5237-5243. Under the General Rating Formula for Diseases and Injuries of the Spine, a 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. The Veteran was afforded a VA examination in September 2014. At the September 2014 VA examination, the Veteran exhibited forward flexion of the thoracolumbar spine to 70 degrees. The VA examiner noted the Veteran reported pain occurring too frequently to be considered a flare-up. However, the examiner also noted the Veteran’s reports of frequent flare-ups of low back pain. The Veteran reported his functional impairment as less movement than normal, weakened movement and pain on movement. The examiner indicated he could not estimate the degree of additional range of motion loss because it was not feasible to provide the degree of additional range of motion because the Veteran was not experiencing a flare-up at the time of the examination and the pain and disturbance of function would be speculative. Additionally, the Board notes that the Veteran has been taking pain medication for his low back pain throughout the appeal period. The use of pain medication was not considered by the any of the VA examiners, and the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Thus, after considering the Veteran’s increased functional loss during flare-ups and with repeated use over time, as well as his use of pain medication, the Board finds that the Veteran’s low back disability more nearly approximates forward flexion of the thoracolumbar spine to no more than 30 degrees. Affording the Veteran the benefit of the doubt, the Board finds that a rating of 40 percent for his low back disability warranted for the entire period on appeal. Entitlement to a rating in excess of 40 percent for degenerative disc disease A 40 percent disability rating is the highest available for limitation of range of motion of the lumbar spine. The Veteran is now in receipt of a 40 percent disability rating for his service-connected degenerative disc disease for the entire appeal period. Under the General Rating Formula for Diseases and Injuries of the Spine, the criteria for a rating in excess of 40 percent require unfavorable ankylosis. There is no objective medical evidence showing ankylosis of the Veteran’s spine. Hence, a rating in excess of 40 percent is not warranted at any time during the appeal period. In this case, a thorough review of the record, to include the VA examinations and treatment records, does not reflect the Veteran has ever been found to have ankylosis of the spine. Further, the recent September 2016 VA examination explicitly found the Veteran did not have ankylosis of the spine. Consequently, he is not entitled to a rating in excess of 40 percent under the General Rating Formula for Diseases and Injuries of the Spine. The Board also notes that as 40 percent is the highest schedular rating for limitation of motion of the spine, the regulatory provisions (38 C.F.R. §§ 4.40, 4.45) pertaining to functional loss are not for application. Spencer v. West, 13 Vet. App. 376, 382 (2000); Johnston v. Brown, 10 Vet. App. 80, 85 (1997); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Finally, a higher rating is not warranted under the Formula for Rating IVDS Based on Incapacitating Episodes because the evidence does not show that the Veteran suffered from incapacitating episodes having a total duration of at least 6 weeks at any point during the appeal period. For these reasons, the Board finds that he does not meet or nearly approximate the criteria for a rating in excess of 40 percent for his service-connected degenerative disc disease, to include as a “staged” rating(s). REASONS FOR REMAND 1. Entitlement to service connection for right hip strain and left hip, to include as secondary to service-connected degenerative disc disease (DDD), lumbar spine with residuals, discectomy, L4-L5 is remanded. The Veteran asserts that his right hip and left hip conditions are related to him sitting in a chair and the chair collapsing during service or secondarily to his service-connected back condition. The Veteran has been diagnosed right hip and left strain. In September 2014, the Veteran was provided a VA examination. The VA examiner opined that the Veteran’s hip conditions is less likely than not proximately due to or the result of the Veteran’s service-connected degenerative disc disease. He reasoned that the Veteran’s hip conditions are a straining of the muscle, which is not caused by degeneration in the spinal column; however, the examiner did not address whether the Veteran’s right hip and left hip conditions are the result of falling to the ground after his chair collapsed. Additionally, in September 2015, the Veteran submitted physical functional capacity questionnaire that indicated the Veteran’s right hip and left hip strain are at least as likely as not related to service. The examiner opined that the Veteran’s symptoms first appeared in service after the initial injury. The Veteran had surgery with continued pain. He stated, he felt the hip strain occurs due to postural compensation for the low back with radiculopathy. Clarity is needed regarding this matter. The Board finds that a VA examination is warranted to consider whether the Veteran’s right hip and left hip conditions are related to his active duty service, or whether the Veteran’s service-connected degenerative disc disease caused or aggravated any currently diagnosed right hip condition or left hip condition. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected degenerative disc disease, lumbar spine residuals, discectomy, L4-L5 is remanded. The Veteran asserts that he is entitled to service connection for hypertension which he believes he developed as a result of his service-connected degenerative disc disease. The Veteran’s treatment records show diagnosis and treatment of hypertension. See November 2014 Primary Care Progress Note. In September 2014 the Veteran was provided a VA examination. The VA examiner noted a diagnosis of hypertension. The examiner opined that the Veteran’s hypertension is less likely than not due to the Veteran’s back condition. He reasoned that hypertension is not caused by degenerative disc disease but did not provide any support for the conclusion. A contemporaneous VA examination is necessary to determine whether the Veteran’s degenerative disc disease caused or aggravated his hypertension. The matters are REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and/or post-service right hip and/or left hip problems and hypertension. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Schedule the Veteran for an appropriate VA examination to determine the onset and/or etiology of his claimed right hip disability and left hip disability. The examiner is asked to review the entire claims file, to include the Veteran’s competent lay report regarding the onset of his left hip and right hip problems, all medical evidence of record, and undertake any studies deemed necessary. Then, based on the results of the examination, the examiner must diagnose all current right hip disabilities and left hip disabilities found to be present. a. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any currently diagnosed right hip disabilities, and left hip disabilities are related to and/or had their onset during his period of service. The examiner should consider the Veteran’s reports of an in-service fall as a result of a chair collapsing. b. The examiner must further opine as to whether the Veteran’s service-connected degenerative disc disease, caused or aggravated (permanently worsened) any currently diagnosed right hip disability and/or left hip disabilities. The term “aggravation” means a permanent increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any diagnosed right hip disabilities and/or left hip disabilities, by the Veteran’s service-connected degenerative disc disease is found, the examiner must attempt to establish a baseline level of severity of the diagnosed right hip disabilities and left hip disabilities, prior to aggravation by the service-connected disability. The examination report must include a complete rationale for all opinions expressed. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension. The examiner must provide opinions as to the following: a. Whether it is at least as likely as not that the Veteran’s hypertension is proximately due to or the result of his service-connected back condition. The examiner must consider any medication(s) the Veteran takes related to his service-connected disabilities. b. Whether it is at least as likely as not that the Veteran’s hypertension was aggravated (permanently worsened beyond the natural progression of the disease) by his service-connected back condition. The examiner must provide all findings, along with a complete rationale for all opinions expressed. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jacquelynn M. Jordan, Associate Counsel