Citation Nr: 18153213 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-15 810A DATE: November 27, 2018 ORDER The claim of entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD) with major depressive disorder prior to October 26, 2016, is denied. The claim of entitlement to a disability rating in excess of 70 percent for PTSD with major depressive disorder beginning on October 26, 2016, is denied. REMANDED Entitlement to a higher disability rating for degenerative disc disease of the thoracic spine, rated as 10 percent prior to October 25, 2016, and 20 percent thereafter is remanded. Entitlement to a disability rating in excess of 10 percent for allergic urticaria with anaphylaxis. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a neurologic disorder of the right lower extremity is remanded. Entitlement to service connection for a neurologic disorder of the left lower extremity is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. Prior to October 26, 2016, the Veteran’s PTSD with major depressive disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; it has not been productive of occupational and social impairment which most nearly approximates reduced reliability and productivity. 2. Beginning on October 26, 2016, the Veteran’s PTSD with major depressive disorder has been productive of occupational and social impairment with deficiencies in most areas; it has not been productive of total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to October 26, 2016, the criteria for a disability rating in excess of 30 percent for PTSD with major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Codes 9411 and 9434 (2018). 2. For the period beginning on October 26, 2018, the criteria for a disability rating in excess of 70 percent for PTSD with major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Codes 9411 and 9434 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Air Force from December 2002 to October 2006. In July 2018, the RO increased the disability ratings assigned for degenerative disc disease of the thoracic spine to 20 percent, effective October 25, 2016, and for major depressive disorder with PTSD to 70 percent, effective October 26, 2016. However, because the increased disability ratings assigned are not the maximum rating available throughout the period on appeal, the claims remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. In Brokowski v. Shinseki, 23 Vet. App. 79 (2009), the Court extended the holding of Clemons to include disabilities outside of psychiatric disorders. In compliance with this case law, the Board considers the Veteran’s claims of entitlement to service connection for bilateral lower extremity radiculopathy as one that encompasses any neurologic disorder of the lower extremities. Duties to Notify and Assist Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 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 questions as to which of two evaluations apply, assigning a 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). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2018). 1. Entitlement to a higher disability rating for the service-connected psychiatric disorder, rated as 30 percent prior to October 26, 2016, for major depressive disorder, and in excess of 70 percent thereafter (and combined with PTSD on January 17, 2017). At the outset, the Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran’s service-connected psychiatric disorder is currently rated as 30 percent disabling prior to October 26, 2016, and 70 percent thereafter pursuant to the criteria of 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9434, which are included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130. According to the General Rating Formula for Rating Mental Disorders, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, and recent events. 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9434. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The maximum 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in Diagnostic Codes 9411 and 9434 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under Diagnostic Codes 9411 and 9434 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms associated with the Veteran’s psychiatric disorder that affect the level of occupational and social impairment, including, those identified in the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5). After a review of all the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence of record does not support a rating greater than 30 percent prior to October 26, 2016. Throughout this period, the Veteran’s major depressive disorder symptoms predominantly included anxiety, chronic sleep impairment, irritability, lack of motivation, fatigue, low energy, decreased appetite, worthlessness, hopelessness, isolation, and disturbances of motivation and mood. The Board acknowledges that the medical records showed disturbances of motivation and mood, however, the evidence of record does not show that it was so severe as to result in reduced reliability and productivity. Mental status examinations revealed good grooming and hygiene, fair eye contact, full orientation, calm and cooperative behavior, intact concentration, clear and normal speech, dysphoric or agitated mood, congruent and appropriate affect, coherent, logical, and goal-oriented thought process, fair to poor insight, and fair to poor judgment. She denied suicide attempts, but stated that she engaged in self-cutting in the past. There was no evidence of hallucinations, delusions, or homicidal ideations. The November 2013 VA examiner concluded that her major depressive disorder caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. With regard to social impairment, at the time of the November 2013 VA examination she was married for one year and was going through a divorce. Her first marriage was in 2001 and they divorced in 2009 due to incompatibility issues. In June 2015, she was living with her girlfriend. She also had a 7 year old daughter and had regular contact with her father and most of her siblings. With regard to occupational impairment, the Veteran was a fulltime student at the University of Texas majoring in nursing. She was not employed. In June 2015, the Veteran failed out of school. She attributed her problems with school to her impaired concentration. Based on the above, the Board finds that for the period prior to October 26, 2016, the Veteran was not shown to have occupational and social impairment with reduced reliability and productivity. For the period beginning on October 26, 2016, the Veteran has not shown to have total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. During this period, the Veteran’s psychiatric symptoms predominantly included anger, irritability, anhedonia, insomnia, hypersomnia, psychomotor agitation, anergia, diminished ability to concentrate, feelings of worthlessness, suicidal ideation, poor social relationships, distrust of others, difficulty concentrating, anxiety, paranoia, intrusive memories, nightmares, persistent negative emotional state, diminished interest, reckless and self-destructive behaviors, lack of motivation, significant sadness, decreased appetite, hypervigilance, depressed mood, panic attacks occurring 1-2 times per week, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, feelings of failure, difficulty in establishing and maintaining effective work and social relationships, significant guardedness, neglect of personal appearance and hygiene, significant avoidance of cues, and marked psychological reaction in response to encountering cues. She also expressed an increased inability to cope with her present stressful life events, manifested in emotional dysregulation, decreased tolerance to stress, displays of anger, stress-related paranoia, and increasing frequency of suicidal ideation. The October 2016 VA examiner stated that the Veteran’s major depressive disorder was moderate and that it had increased. The October 2016 and June 2017 VA examiners found that her psychiatric disorder caused occupational and social impairment with reduced reliability and productivity. Mental status examinations revealed good grooming and hygiene; good to poor eye contact; full orientation; cooperative, guarded, and irritable behavior; average or slowed psychomotor activity; normal speech; anxious, dysphoric, agitated, euthymic, or depressed mood; congruent and appropriate affect; coherent, logical, and goal-oriented thought process; good to poor insight; and good to fair judgment. There was no evidence of hallucinations, delusions, self-abuse, aggressiveness, or cognitive impairment. She reported suicidal ideation. During the June 2017 examination, the Veteran stated that she would not have dressed herself or brushed her teeth if she did not have an appointment. With regard to social impairment the Veteran stated that her psychiatric disorder impacted the quality of her relationship with her girlfriend. She described her relationship with her girlfriend as up and down. Subsequent records show that the Veteran remarried in December 2017. She reported that she was the sole caretaker of her daughter and had a good relationship with her. The Veteran did not have close friends and did not maintain relationships with her family of origin. She denied hobbies or interest. With regard to occupational impairment, the Veteran stated that she failed out of school due to concentration and memory problems and that her school did not accommodate her mental health appointments. She last worked in 2007 as a clerk, but had issues because her ex-husband also worked there. She also had difficulty completing tasks at work. Accordingly, the Board finds that the Veteran is not entitled to a higher rating for her service-connected PTSD with major depressive disorder. While the manifestations of her psychiatric disorder fluctuated throughout the appeal period, the symptoms have not more nearly approximated a 50 percent rating prior to October 26, 2016, or a 100 percent rating thereafter. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The claim of entitlement to an evaluation in excess of 30 percent prior to October 26, 2016, and a rating in excess of 70 percent thereafter for PTSD with major depressive disorder must be denied. REASONS FOR REMAND 1. Entitlement to a higher disability rating for degenerative disc disease of the thoracic spine, rated as 10 percent prior to October 25, 2016, and 20 percent thereafter is remanded. The Veteran asserts that the October 2016 VA examination of record does not accurately reflect the severity of her service-connected back disorder. She contends that she reported flare-ups of the spine to the VA examiner, but the October 2016 VA examination report indicates that she did not experience flare-ups. In addition, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of 38 C.F.R. § 4.59. It does not appear that the November 2013 and October 2016 VA examiners conducted Correia compliant testing. Based on the foregoing insufficiencies, a remand is required in order to obtain adequate orthopedic examinations addressing the back disorder. 2. Entitlement to a disability rating in excess of 10 percent for allergic urticaria with anaphylaxis. During the pendency of the appeal, the criteria for rating urticaria under 38 U.S.C. § 4.118, Diagnostic Code 7825, were revised, effective July 13, 2018. The announcement of the final regulation specifically states that “claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied.” In this regard, if a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); VAOPGCPREC 7-2003. Amendments with a specified effective date without provision for retroactive application may not be applied prior to the effective date. As of that effective date, the Board must apply whichever version of the rating criteria is more favorable to the veteran. In this case, either the old or revised rating criteria may apply, although the new rating criteria are only applicable since their effective date. VAOPGCPREC 3-2000. Prior to July 13, 2018, the criteria for urticaria were based on the severity and number of episodes per year, as well as the type of treatment used. A 10 percent rating was warranted for recurrent episodes of urticaria occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics. 38 C.F.R. § 4.118, Diagnostic Code 7825. A 30 percent rating was warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. Id. A maximum 60 percent rating was warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. Id. Under the revised code, the criteria for chronic urticaria are based on the disorder’s response to required treatment. A 10 percent is warranted for chronic urticaria that requires first line treatment (antihistamines) for control. 38 C.F.R. § 4.118, Diagnostic Code 7825 (effective July 13, 2018). A 30 percent is warranted for chronic urticaria that requires second line treatment (e.g. corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil inhibitors, thyroid hormone) for control. Id. A maximum 60 percent is warranted for chronic refractory urticaria that requires third line treatment for control (e.g. plasmapheresis, immunotherapy, immunosuppressives) due to ineffectiveness with first and second line treatments. Chronic urticaria is defined as continuous urticaria at least twice per week, off treatment, for a period of six weeks or more. Id. The Veteran’s urticaria with anaphylaxis was most recently examined in February 2014. At that time, the examiner noted that she treated her symptoms with antihistamines. A physical examination did not reveal any visible skin conditions. In October 2016, the Veteran wrote a letter to her VA treatment providers requesting correction of her medical records. She stated that her VA treatment providers incorrectly described her anaphylaxis as controlled. The Veteran explained that she continued to experience at least five episodes per month despite treatment. She also explained that she had to leave her environment and remove all of her clothing whenever she had an episode. November 2016 VA treatment records noted a history of anaphylaxis manifested by hives, facial swelling, airway constriction, hot flashes, and generalized pruritis caused by multiple outdoor allergens. It was also noted that she was unable to receive allergy shots because she had too many allergens and the disorder was too severe. March 2017 private treatment records indicated that the Veteran was prescribed albuterol sulf, Singulair, Zyrtec, and Famotidine. February 2018 private treatment records indicated that the Veteran was being treated for anaphylactic episodes. Her doctor recommended that she stop all activity at the moment of each episode. In February 2018, the Veteran stated that she was prescribed four medications for her disorder and that she had over four debilitating episodes per year. She stated that J.V., M.D. treated her disorder since 2017. The Board finds that a remand is required to afford the Veteran another VA examination. The record is not clear as to whether the medication used to treat the Veteran’s allergic urticaria with anaphylaxis is considered immunosuppressive therapy. The Board also finds that a remand is required to evaluate the Veteran’s disorder under the revised criteria. As noted above, higher ratings under the revised criteria are warranted for chronic urticaria that requires second line or third line treatments, however, the most recent VA examination report does not include information to rate the disorder under the new criteria. Finally, it does not appear that all of her records from Dr. V. have been associated with the claims file. On remand, the RO must attempt to obtain such records. 3. Entitlement to service connection for a right knee disorder. The Veteran asserts that her right knee disorder is secondary to her service-connected thoracic spine disorder. In the alternative, she asserts that her right knee disorder is directly related to service. The Veteran’s DD-214 indicates that her primary specialty was an aerospace medical service journeyman. In April 2016, the Veteran reported that she worked as a medic for four years during service and that she ran every day for four years. She also completed training exercises involving lifting and carrying individuals that were heavier than her. An October 2016 VA examination report indicated that a right knee strain was diagnosed in 2004. At the time of the examination she reported constant knee pain. The examiner opined that it was less likely as not that the Veteran’s right knee disorder was proximately due to or the result of her service-connected disorder. The rationale included a discussion of leg amputation, which the examiner described as the ultimate disability a leg can suffer. The examiner explained that even amputees do not seem to develop unusual complication in the other knee that can be attributed to the amputation. The examiner also stated that the Veteran showed no evidence of gait compromise. Subsequent VA treatment records indicated that the Veteran received gait training therapy in August 2017. May 2018 VA treatment records include a consult for a knee brace. The October 2016 VA medical opinion was based, at least in part, on the Veteran’s gait being normal. As there are subsequent VA treatment records indicating that the Veteran’s underwent gait training therapy, the Board finds that a remand is required for another VA medical opinion. In addition, the medical opinions did not address direct service connection. Based on the above, the Board finds that another VA examination is warranted. 4. Entitlement to service connection for a neurologic disorder of the right lower extremity. The Veteran’s July 2006 separation examination noted intermittent upper back pain and it appears to suggest associated radiculopathy. In April 2016, the Veteran stated that her lower extremity radiculopathy was secondary to her lower back disorder. She also stated that she complained of left leg numbness during visits with her VA primary care provider. A November 2013 VA examination indicated that normal sensation to light touch, negative straight leg raising test, and no radiculopathy. The October 2016 VA examination report included a diagnosis of lumbosacral root lesion. Notably, the VA examination report noted normal deep tendon reflexes, a normal sensory examination, and a normal straight leg raising test. The examiner concluded that the Veteran did not have radiculopathy. The examiner indicated that a November 2016 electromyography and nerve conduction study revealed lumbosacral root lesion, not elsewhere classified. The examiner opined that it was less likely as not that the lumbosacral root lesion was proximately due to or the result of the Veteran’s service-connected thoracic degenerative disc disease. The examiner stated that thoracic degenerative disc disease does not result in secondary lower extremity lumbosacral root lesion. The Board finds that the October 2016 VA medical opinion is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Specifically, the examiner did not provide adequate rationale in support of the opinion. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, a remand is required to obtain another VA examination. 5. Entitlement to service connection for a neurologic disorder of the left lower extremity. Please see discussion in paragraph 5. 6. Entitlement to service connection for tinnitus. The Veteran’s service treatment records are silent with respect to any complaints of or treatment for tinnitus. A February 2005 health history record showed that the Veteran denied any jobs or hobbies that involved loud noises. A February 2006 pregnancy workplace interview indicated that she worked indoors cleaning medical equipment. She denied being exposed to loud noises or vibrations. A July 2006 report of medical assessment does not contain any complaints of tinnitus symptoms, but documents her complaints of wrist pain, feet pain, and upper back pain. The Veteran’s DD-214 lists her occupational specialty as an aerospace medical service journeyman. The Veteran underwent a VA examination in November 2013. She reported that her tinnitus symptoms started in 2004. The examiner was unable to provide an opinion without resorting to speculation due to the lack of audiograms in the service treatment records. In April 2016, the Veteran reported that she was on the flight medicine team and was tasked with supporting the flight shows during her final duty assignment. She stated that she was exposed to hazardous noise from military equipment. The Veteran was afforded a VA examination in October 2016. The examiner stated that an opinion regarding etiology could not be entered without resorting to speculation. The examiner explained that there were no service treatment records for hearing found in the claims file to determine a shift in hearing. Also, there was no report of tinnitus in the Armed Forces Health Longitudinal Technology Application (AHLTA) records. In October 2017, the Veteran submitted a photo to show that she worked on the flight line. Upon review, the Board finds that the VA examinations are inadequate for adjudication purposes. Barr v. Nicholson, 21 Vet. App. at 312. It does not appear that the VA examiners considered and discussed the Veteran’s lay statements regarding noise exposure during her last duty assignment. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury, but relied on the service treatment records to provide a negative opinion). Accordingly, a remand is required to obtain another VA examination. In addition, as the Veteran asserted that she was exposed to hazardous noise while working on the flight line. The Board finds that her service personnel records should be obtained on remand. The matters are REMANDED for the following action: 1. The RO or AMC should request and obtain complete service personnel records pertaining to the Veteran from the appropriate agency. 2. The RO or the AMC should undertake appropriate development to obtain any outstanding, pertinent VA and private medical records, to include private medical records from J.V., M.D. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 3. Then, the RO or the AMC should afford the Veteran a VA examination by an examiner with sufficient expertise to fully assess the severity of the Veteran’s service-connected degenerative disc disease of the thoracic spine. All pertinent evidence of record should be made available to and reviewed by the examiner. Any indicated studies should be performed. The RO or the AMC should ensure that the examiner provides all information required for rating purposes, to specifically include the results of range of motion testing for pain on both active and passive motion and on weight-bearing and nonweight-bearing. The examiner is also requested to review the VA examination containing range of motion findings pertinent to the Veteran’s back conducted during the course of the appeal. If the examiner is unable to do so, he or she should explain why. In addition, the examiner must determine the extent of any additional limitation of joint motion (in degrees) due to weakened movement, excess fatigability, incoordination, or pain during flare-ups and/or with repeated use. In doing so, the examiner must consider and discuss all procurable and assembled data such as the frequency, duration, characteristics, precipitating and alleviating factors, and the severity of the flare-ups, and then provide an assessment of the functional loss during flares, if possible in degrees of motion lost. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case he or she should clearly explain why that is so. Furthermore, if any opinion cannot be offered without resorting to mere speculation, the examiner should clearly explain why this is the case and identify any additional evidence that may allow for a more definitive opinion. 4. Then, the RO or the AMC should afford the Veteran a VA examination by an examiner with sufficient expertise to fully assess the severity of the Veteran’s service-connected allergic urticaria with anaphylaxis. All pertinent evidence of record should be made available to and reviewed by the examiner. Any indicated studies should be performed. The RO or the AMC should ensure that the examiner provides all information required for rating purposes, under both the former and revised rating criteria. The examiner must determine at what points during the appeal period, e.g. since August 2013, the Veteran used immunosuppressive therapy, second line treatments, and third line treatments. A complete rationale must be provided for all opinions offered, and if the examiner cannot offer an opinion without resorting to mere speculation, the examiner should fully explain why this is the case and identify what additional evidence/information, if any, would allow for a more definitive opinion. 5. Then, the RO or the AMC should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of her right knee disorder. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should address the following: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was incurred in, was caused by, or is otherwise etiologically related to her military service. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was caused by or aggravated by her service-connected degenerative disc disease of the thoracic spine. In providing the requested opinion, the examiner must consider the Veteran’s statements regarding her in-service duties as a medic. A complete rationale must be provided for all opinions offered, and if the examiner cannot offer an opinion without resorting to mere speculation, the examiner should fully explain why this is the case and identify what additional evidence/information, if any, would allow for a more definitive opinion. 6. Then, the RO or the AMC should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran’s bilateral lower extremity neurologic disorder. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner must identify all neurologic disorders of the bilateral lower extremity. Then the examiner must address the following with respect to each disorder: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was incurred in, was caused by, or is otherwise etiologically related to her military service. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was caused by or aggravated by her service-connected degenerative disc disease of the thoracic spine. The examiner must consider and discuss the July 2006 service treatment record noting radiculopathy and the November 2016 electromyography and nerve conduction study. A complete rationale must be provided for all opinions offered, and if the examiner cannot offer an opinion without resorting to mere speculation, the examiner should fully explain why this is the case and identify what additional evidence/information, if any, would allow for a more definitive opinion. 7. Then, the RO or the AMC should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran’s tinnitus. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was incurred in, was caused by, or is otherwise etiologically related to her military service. In doing so, the examiner must consider and discuss the lay statements regarding onset of tinnitus symptoms and in-service noise exposure. A complete rationale must be provided for all opinions offered, and if the examiner cannot offer an opinion without resorting to mere speculation, the examiner should fully explain why this is the case and identify what additional evidence/information, if any, would allow for a more definitive opinion. 8. Finally, the RO or the AMC should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and her representative should be furnished an appropriate (CONTINUED ON NEXT PAGE) supplemental statement of the case and be afforded the requisite opportunity to respond. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. N. Nolley, Associate Counsel