Citation Nr: 18151729 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 15-29 961 DATE: November 20, 2018 ORDER Entitlement to an evaluation in excess of 30 percent for reactive airway disease with bronchial asthma, residual of right lower lobectomy, is denied. Entitlement to an initial compensable evaluation for status-post laceration and residual scar on the top of scalp is denied. Entitlement to a compensable evaluation for right upper chest scar, residual of cyst removal, is denied. Entitlement to an initial compensable evaluation for residual scars in the left posterior chest wall due to chest tube placement and status-post right thoracotomy is denied. Entitlement to special monthly compensation (SMC) at the “k” rate is denied. FINDINGS OF FACT 1. Throughout the applicable period, exercise induced asthma has not manifested by forced expiratory volume in one second (FEV-1) of 40 to 45 percent or less predicted, or the ratio of FEV-1 to forced vital capacity (FVC) of 40 to 45 percent or less, at least at least monthly visits to a physician for required care of exacerbations, intermittent (at least 3 times per year) courses of systemic (oral or parenteral) corticosteroids, more than one attack per week with episodes of respiratory failure, or requiring daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 2. Throughout the applicable period, the residual linear scar on the Veteran’s scalp did not manifest by deep scarring, pain or any underlying tissue loss, or any characteristics of disfigurement, visible or palpable tissue loss, or assymetry of any feature or paired set of features. 3. Throughout the applicable period, the 1 cm linear right upper chest scar, residual of cyst removal, did not manifest by deep and nonlinear scarring, instability, pain or underlying soft tissue damage. 4. Throughout the applicable period, the linear scar of the posterior trunk measured 22 cm by .05 cm, but did not manifest by deep and nonlinear scarring, instability, pain or underlying soft tissue damage. 5. At no point has it been demonstrated that the Veteran has anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, having absence of air and bone conduction, or complete organic aphonia with constant inability to communicate by speech. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial evaluation in excess of 30 percent for reactive airway disease with bronchial asthma, residual of right lower lobectomy, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.97, Diagnostic Code 6602 (2017). 2. The criteria for entitlement to an initial evaluation in excess of 10 percent for status-post laceration and residual scar on the top of scalp have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805 (2017) and Diagnostic Codes 7801-7805 (revised effective August 13, 2018). 3. The criteria for entitlement to a compensable evaluation for right upper chest scar, residual of cyst removal have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805 (2017) and Diagnostic Codes 7801-7805 (revised effective August 13, 2018). 4. The criteria for entitlement to an initial compensable evaluation for residual scars in the left posterior chest wall due to chest tube placement and status-post right thoracotomy have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805 (2017) and Diagnostic Codes 7801-7805 (revised effective August 13, 2018). 5. Entitlement to special SMC at the “k” rate have not been met. 38 U.S.C. §§ 1114(k), 5107 (2012); 38 C.F.R. §§ 3.102, 3.350, 3.352(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. 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. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates “staged ratings” where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, “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). 1. Entitlement to an evaluation in excess of 30 percent for reactive airway disease with bronchial asthma, residual of right lower lobectomy. As provided by VA’s Schedule for Rating Disabilities, a 10 percent rating is assigned for bronchial asthma where pulmonary function testing reveals that forced expiratory volume in one second (FEV-1) is 71 to 80 percent predicted, the ratio of FEV-1 to forced vital capacity (FVC) (FEV-1/FVC) is 71 to 80 percent, or where intermittent inhalational or oral bronchodilator therapy is used. 38 C.F.R. § 4.97, Diagnostic Code 6602. A 30 percent rating is assigned where pulmonary function testing reveals that FEV-1 is 56 to 70 percent predicted, FEV-1/FVC is 56 to 70 percent, or daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication, is used. Id. A 60 percent rating is assigned where pulmonary function testing reveals that FEV-1 is 40 to 55 percent predicted, FEV-1/FVC is 40 to 55 percent, or where at least monthly visits to a physician are needed for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids are used. Id. The highest rating allowable under this diagnostic code, 100 percent, requires evidence of FEV-1 less than 40 percent predicted, FEV-1/FVC less than 40 percent, more than one attack per week with episodes of respiratory failure, or the daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. Id. In the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, Note following Diagnostic Code 6602. The post-bronchodilator findings from the pulmonary function tests (PFTs) are the standard in pulmonary assessment. See 61 Fed. Reg. 46720, 46723 (Sept. 5, 1996) (VA assesses pulmonary function after bronchodilation as these results reflect the best possible functioning of an individual). VA amended the rating schedule concerning respiratory conditions, effective October 6, 2006. VA added provisions that clarify the use of pulmonary function tests (PFTs) in evaluating respiratory conditions. A new paragraph (d) to 38 C.F.R. § 4.96, titled “Special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845” was added. Because the amendment does not pertain to Diagnostic Code 6602, these changes have no bearing on the present case. The Veterans asthma is properly addressed under 38 C.F.R. § 4.97, Diagnostic Code 6602 as this code provides specifically for the evaluation thereof. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). During his December 2011 VA examination, the Veteran related shortness of breath at rest, but no cough or any asthma attacks. He had no episodes of respiratory failure. He used an inhaler, one puff, twice daily, and took montelukast (Singulair) once daily. He was not receiving any treatment for his asthma. He described flare-ups necessitating rest on occasion. FEV-1 was 81 percent predicted pre-bronchodilation, and 87 percent post-bronchodilation. FEV-1/FVC was 74 percent predicted pre-bronchodilation, and 78 percent post-bronchodilation. There was no evidence of bronchospasm, and spirometry was interpreted as normal. The Veteran was examined by VA again in March 2016. The examination report notes that the Veteran’s respiratory condition did not require the use of oral or parenteral corticosteroid medications, but rather the use of inhalational bronchodilator therapy and inhalational anti-inflammatory medication on a daily basis. The Veteran also continued to take Singulair. The condition did not require the use of oral bronchodilators, the use of antibiotics, or outpatient oxygen therapy. There was no history of asthma attacks with episodes of respiratory failure in the past 12 months. The Veteran had not been to a physician for required care of exacerbations. FEV-1 was 90 percent predicted pre-bronchodilation, and 86 percent predicted after bronchodilation. FEV-1/FVC was 100 percent predicted pre-bronchodilation, and 99 percent post-bronchodilation. In the rating decision forming the basis of the present appeal, the RO assigned a 30 percent evaluation for the Veteran’s disability based upon a finding that it required the daily use of oral bronchodilators. Under the rating criteria, schedular evaluations of 60 and 100 percent are still available. Entitlement to an evaluation in excess of 30 percent for reactive airway disease with bronchial asthma, residual of right lower lobectomy, is denied. In order to substantiate a 60 percent evaluation, the evidence must indicate that FEV-1 is 40 to 55 percent predicted or FEV-1/FVC is 40 to 55 percent, or that the condition requires at least monthly visits to a physician for required care of exacerbations, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. To substantiate a 100 percent evaluation, the evidence must indicate FEV-1 or FEV-1/FVC of less than 40 percent, or more than one attack per week with episodes of respiratory failure, or the daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. Here, FEV-1 and FEV-1/FVC have never approximated 55 percent or less. While the Veteran has reported exacerbations, he does not receive any treatment for them, and no exacerbations are shown in the clinical records. He has not been prescribed corticosteroids or immunosuppressive medications at any dose. Accordingly, entitlement to a 30 percent evaluation is denied. Hart, supra. 2. Entitlement to an initial evaluation in excess of 10 percent for status-post laceration and residual scar on the top of scalp. 3. Entitlement to a compensable evaluation for right upper chest scar, residual of cyst removal. 4. Entitlement to an initial compensable evaluation for residual scars in the left posterior chest wall due to chest tube placement and status-post right thoracotomy. Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the eight characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: (1) scar is 5 or more inches (13 or more cm) in length; (2) scar is at least one-quarter inch (0.6 cm) wide at the widest part; (3) surface contour of scar is elevated or depressed on palpation; (4) scar is adherent to underlying tissue; (5) skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm); (6) skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm); (7) underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm); and (8) skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm). 38 C.F.R. § 4.118, Diagnostic Code 7800 at Note (1). Diagnostic Code 7800 provides that a 10 percent rating is warranted for a skin disorder of the head, face, or neck with one characteristic of disfigurement. A 30 percent rating is warranted for a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent evaluation is provided for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, with four or five characteristics of disfigurement. A schedular maximum 80 percent is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, with six or more characteristics of disfigurement 38 C.F.R. § 4.118, Diagnostic Code 7800. Deep and nonlinear scars that are not of the head, face, or neck are evaluated as follows: area of 144 sq. in. or greater (40 percent); area of 72-144 sq. in. (30 percent); area of 12-72 sq. in. (20 percent); and area of 6-12 sq. in. (10 percent). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2017). Diagnostic Code 7801, Note (1) defines a deep scar as “one associated with underlying soft tissue damage.” Superficial and nonlinear scars that are not of the head, face, or neck are evaluated as follows: area of 144 sq. in. or greater (10 percent). 38 C.F.R. § 4.118, Diagnostic Code 7802 (2017). Diagnostic Code 7802, Note (1) defines a superficial scar as “one not associated with underlying soft tissue damage.” Unstable or painful scars are evaluated as follows: five or more scars that are unstable or painful (30 percent); three or four scars that are unstable or painful (20 percent); and one or two scars that are unstable or painful (10 percent). 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7804, Note (2) allows for an extra 10 percent rating for a single scar that is both unstable and painful. Diagnostic Code 7804, Note (1) defines an unstable scar as “one where, for any reason, there is frequent loss of covering of skin over the scar.” Diagnostic Code 7805 directs consideration of disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 under any other appropriate diagnostic code. The schedular criteria for evaluating scars are set out at 38 C.F.R. § 4.118, Diagnostic Code 7800-7805. Effective August 13, 2018, changes were made to the rating criteria for skin disabilities (38 C.F.R. § 4.118). See 83 Fed. Reg. 32,592 (July 13, 2018). The old regulation will be considered for periods both before and after the effective date of the regulatory change. However, the revised criteria will be applied if favorable to the claim from the effective date of the regulatory change. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). To summarize, the revisions to Diagnostic Codes 7801, 7802, and 7805, pertaining to scars: (1) replace the deep/nonlinear/superficial terminology in Diagnostic Code 7801 and 7802 with underlying soft tissue damage; (2) streamline the body parts/areas into six zones of the body, defined as each extremity, the anterior trunk and the posterior trunk (Note 1 to Diagnostic Codes 7801 and 7802); and (3) indicate how to assign separate evaluations for each affected zone of the body under § 4.25 (Note 2 to Diagnostic Codes 7801 and 7802). Scalp Scar During VA examination in March 2011, the Veteran described a scar on the top right part of his head, caused by staples to the scalp, as well as a scar related to trauma. He reported the scars were not painful, and did not break down. He denied any other symptoms and that the scars caused any functional limitations. Examination reflected a linear scar on the top of the scalp measuring 0.5 cm by 0.2 cm. The scar was not painful on examination, and there was no skin breakdown. The scar was described as superficial, with no underlying tissue damage. There was no edema, inflammation or keloid formation. The scar was not disfiguring and did not limit motion or function. Photographs show no disfigurement and that the scar was obscured by hair. The Veteran was next examined in March 2016. He denied that the scalp scar was painful and/or unstable. Examination reflected a 2 cm x 0.3 cm linear scar on top of the scalp obscured by hair. The Veteran’s scalp scar is evaluated under Diagnostic Code 7800, which provides for evaluation of scars and disfigurement of the head, face or neck. 38 C.F.R. § 4.118. VA examinations have repeatedly shown that this scar is linear, and measures 2 cm by 0.3 cm, at its widest, and there are no indications of tissue loss and either gross distortion or assymetry of any paired sets of features. The scar exhibits no characteristics of disfigurement. See 38 C.F.R. § 4.118, Note (1). Accordingly, a compensable evaluation is not warranted under Diagnostic Code 7800. Fenderson, supra. Moreover, because the scalp scar is linear, and has never exhibited pain or underlying soft tissue damage, i.e. deep scarring, a compensable evaluation is not warranted under Diagnostic Code 7804. 38 C.F.R. § 4.118. Upper Chest Scar During VA examination in December 2011 the Veteran described a scar on the right upper side of the chest caused by cyst removal surgery. He stated that the scar was not painful. The scar did not experience skin breakdown, and the Veteran denied any other symptoms. There was no functional impairment caused by the scar. Examination disclosed a scar on the anterior trunk precisely located at the interpectoral region below the sternoclavicular joint. The scar was linear and measured 0.5 cm by .02 cm. The scar was not painful, and did not exhibit breakdown. The scar was superficial with no underlying tissue damage. There was no inflammation, edema or keloid formation. The scar was not disfiguring and did not limit motion or function. VA examination in March 2016 reflects a 1 cm superficial linear scar related to cystectomy. The scar was not painful or unstable. It did not cause limitation of motion or function. The Veteran reported that the scar itched on occasion. Here, the Board notes that Diagnostic Codes 7801, 7802 and 7804 do not provide for a compensable evaluation. No scarring has been characterized as “deep and nonlinear” or as associated with underlying soft tissue damage, such that a compensable evaluation would be warranted under Diagnostic Code 7801. With respect to Diagnostic Code 7802, the scar does not approximate an area of 144 sq. in. (929 sq. cm.). Moreover, the scar is not unstable or painful, such that a compensable evaluation would be warranted under Diagnostic Code 7804. 38 C.F.R. § 4.118. Accordingly, the claim is denied. Hart, supra. Chest Wall Scars At the December 2011 VA examination, the Veteran related that he had two scars on the right side of the mid torso from the insertion of chest tubes related to his lobectomy. He also described a scar on the right side of the back, also related to the lobectomy. With respect to the chest tube scarring, the Veteran stated that it was not painful, but rather itched. He denied skin breakdown. With respect to the scarring of the right side of the back, the Veteran reported that it was not painful and did not exhibit skin breakdown. He related that it itched and that he had a feeling of numbness about the scar. He denied any functional impairment from the scars. Physical examination showed a linear 22 cm by 0.5 cm scar on the posterior side of the trunk precisely below mid-thorax. The scar was not painful. There was no skin breakdown. The scar was superficial with no underlying tissue damage. There was no inflammation, edema or keloid formation. The scar was not disfiguring and did not limit motion or function. With respect to the chest tube scarring, examination showed a scar on the posterior side of the trunk and one scar on the lateral thorax. The scars were linear, and measured 2 cm x 0.5. The scars were not painful. There was no skin breakdown. The scar was superficial with no underlying tissue damage. Inflammation was absent. Edema was absent. There was no keloid formation, and the scar was not disfiguring. There was no limitation of function or motion due to the scar. VA examination in March 2016 disclosed a linear 25 cm scar posterior hemothorax, as well as 2 linear scars each measuring 2 cm related to the chest tube placement. None of the scars was painful or unstable, although the Veteran apparently reported that the scars were occasionally itchy. Here, the Board notes that Diagnostic Codes 7801, 7802 and 7804 do not provide for a compensable evaluation. No scarring has been characterized as “deep and nonlinear” or as associated with underlying soft tissue damage, such that a compensable evaluation would be warranted under Diagnostic Code 7801. With respect to Diagnostic Code 7802, the scarring does not approximate an area of 144 sq. in. (929 sq. cm.). Moreover, the scars are not unstable or painful, such that a compensable evaluation would be warranted under Diagnostic Code 7804. 38 C.F.R. § 4.118. Accordingly, the claim is denied. Fenderson, supra. The Board acknowledges that the Veteran has asserted that the scarring of the posterior trunk has resulted in limitation of motion and function. He is certainly competent to report his lay observations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). However, repeated VA examinations have documented no limitation of motion or function resulting from this scarring. The Board finds more probative the clinical evidence, and finds that the posterior trunk scarring does not result in any limitation of function or motion such that evaluation under another diagnostic would be warranted. 5. Entitlement to special monthly compensation (SMC) at the “k” rate. Special monthly compensation under 38 U.S.C. 1114(k) is payable for each anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, having absence of air and bone conduction, or complete organic aphonia with constant inability to communicate by speech. The Veteran seeks entitlement to SMC based on the partial removal of his right lung. However, SMC at the “k” rate is not payable for the partial lobectomy, as outlined above. Accordingly, the claim is denied. REMANDED Entitlement to an initial evaluation in excess of 10 percent for a right ankle sprain is remanded. Entitlement to service connection for a TBI is remanded. REASONS FOR REMAND 1. Entitlement to an initial evaluation in excess of 10 percent for a right ankle sprain is remanded. The Court held that with respect to flare-ups, VA examiners must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation, including by soliciting information regarding frequency, duration, characteristics, severity, or functional loss. Sharp v. Shulkin, 29 Vet. App. 26 (2017). During the most recent VA examination, the Veteran described flare-ups of his right ankle disability with increased pain. However, the examiner concluded he was unable to state, without resorting to speculation, whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups because the Veteran would need to be examined during a flare-up and have a comparison on which to base any additional limitation of motion. Additional findings regarding functional loss during flare-ups should be addressed in the additional examination 2. Entitlement to service connection for a traumatic brain injury (TBI) In March 2017, VA offered the Veteran the opportunity to have a new TBI examination performed by a specialist. In May 2017, the Veteran responded that he desired to have another TBI examination. To date, no examination has been performed. Accordingly, the matter is remanded to afford the Veteran such an examination. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination in order to ascertain the current severity of his service-connected right ankle disability. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted, and the results included in the examination report. The claims file, including a copy of this remand should be reviewed in conjunction with this examination. In assessing the severity of the right ankle disability, the examiner should test for pain on both active and passive motion, in weight-bearing and non-weight bearing, and if possible, each joint should be contrasted with the range of the opposite undamaged joint. Any further testing deemed necessary should also be conducted and the results recorded in detail. The examiner should, if possible, note facial expressions of pain, crepitation in soft tissues and joint structures, and test for pain throughout range of motion in the various ways described above. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. An estimate of additional degrees of limitation of motion during the flare-ups should be provided. If the examiner is unable to estimate functional loss in terms of degrees of motion after physical examination and eliciting the pertinent information about the flare-ups above, he or she must explain why and may not rely solely upon his or her inability to personally observe the Veteran during a period of flare-up. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). 2. Schedule the Veteran for a TBI examination to be conducted by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon), as well as any other necessary development. Arrange for the Veteran’s electronic claims file, including a copy of this remand, to be reviewed by the VA examiner. Following review of the claims file, the examiner should render an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran’s claimed TBI is etiologically related to his military service, to include the head injury when he struck a shelf with his head. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner should provide rationale for the opinions. The examiner is asked to explain the reasons behind any opinion expressed and conclusion reached. (Continued on the next page)   If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joseph R. Keselyak