Citation Nr: 18153290 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-11 191A DATE: November 27, 2018 ORDER An initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a right hand disability (originally claimed as a right wrist disability) is remanded. Entitlement to service connection for a left hand disability (originally claimed as a left wrist disability) is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left leg disability, to include as due to a back disability is remanded. Entitlement to service connection for a skin disability, to include as due to herbicide agent exposure is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to April 3, 2014, is remanded. FINDING OF FACT The Veteran’s PTSD does not more nearly approximate total social impairment. CONCLUSION OF LAW The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant in this case, had service from February 1967 to December 1969. The Board notes that the TDIU issue was raised during the course of the appeal, and subsequently granted since April 3, 2014; however, the issue has been staged to address the prior rating period that is still part of the current appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. The Court essentially stated that a request for a total disability rating—whether expressly raised by a Veteran or reasonably raised by the record—is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Id. at 453-54. The Board acknowledges the Veteran's disagreement with the effective date assigned for the TDIU awarded by the February 2016 rating decision and April 2016 notification letter. However, the matter of the proper effective date for the grant of TDIU is already on appeal, inasmuch as the Board is required to consider whether staged ratings are warranted and to consider the evaluation for the entire period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also A.B. v. Brown, 6 Vet. App. 35 (1993). Consequently, even though the Veteran submitted a substantive appeal regarding the purported effective date claim, this does not result in a new issue before the Board. The TDIU issue on appeal is more accurately reflected as a staged rating claim rather than as an effective date claim, and therefore will continue to be characterized as reflected on the title page. Moreover, there is no prejudice to the Veteran from this characterization. The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence in the record; not every item of evidence has the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018). The Court has held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. See Gilbert, 1 Vet. App. at 53. The Court has also stated, “It is clear that 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. PTSD Rating The Veteran contends that his service-connected PTSD is more severe than the initial 70 percent rating assigned under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where, as here, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code (DC or Code) 9411. Under this General Rating Formula, a 70 percent rating is warranted for 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. Finally, a total, or 100 percent, rating is awarded on evidence of 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; memory loss for names of close relatives, own occupation, or own name. Id. The VA Secretary, acting within his authority to “adopt and apply a schedule of ratings,” chose to create one General Rating Formula for Mental Disorders. 38 U.S.C. §§ 501, 1155; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary’s use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant’s social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002) (holding that “the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment”). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA “intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms.” The Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Id. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been officially released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, No. 16-1208, Slip opinion at 5 (Vet. App. Feb. 23, 2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. The Court added that it does not hold that the Board commits prejudicial error every time the Board references GAF scores in a decision. This appeal was initially certified to the Board in October 2017 and the file was first transferred to the Board in November 2017, so it was pending before the Board after August 4, 2014. As such, the DSM-IV does not apply and the GAF scores will not be discussed. After a full review of the record, and as discussed below, the Board finds that the Veteran’s psychiatric symptoms do not more nearly approximate a 100 percent rating. The evidence of record reflects that the Veteran’s PTSD was productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to such symptoms as depressed mood, anxiety, chronic sleep impairment, suspiciousness, mild memory loss, disturbances in motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran received an initial VA examination in November 2011. The examiner diagnosed PTSD and no other mental health disorder. The Veteran told the examiner that he was still married to the same woman after 41 years and that he has personal relationships with his children and grandchildren that he sees “all the time.” He also said that his friends visit him at home. He described being hypervigilant and lived in the country to avoid frequent loud noises. He stated that he last had suicidal ideation “several months ago,” but did not make any attempts and did not have any such ideations after his daughter became pregnant again. The Veteran also said that he started going to church and that it helped him. He further said that he does not think of or plan to harm himself or others. He denied hallucinations and there was no evidence of delusions. He described short memory problems and his attention span. He also exhibited tearful emotions off and on during the examination. The examiner reported that the Veteran was oriented to all spheres. His speech was easily understood and his thought process was goal oriented. He had good eye contact, short term memory, serial sevens, and spelling “world” forward and backward. His intellect was normal. His affect was broad and appropriate while his insight and judgment were fair. The November 2011 VA examiner found that the Veteran’s PTSD exhibited occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to the following symptoms: depressed mood, anxiety, chronic sleep impairment, mild memory loss, and difficulty establishing and maintaining effective work and social relationships. The examiner reported that there were no other symptoms attributable to PTSD or any other mental disorder. The Veteran was found capable to manage his financial affairs. The examiner remarked that the Veteran has experienced PTSD symptoms since he left military service and had re-experienced symptoms at a high level “over the years.” The examiner continued that spirituality in the past years helped reduce the Veteran’s PTSD symptoms, “especially intrusive thoughts, nightmares, and flashbacks, though they are still occurring at clinically significant levels.” The Veteran received another VA examination in March 2013. He told the examiner that his PTSD symptoms were “pretty much the same, not much difference.” The examiner continued the diagnosis for PTSD with no other mental health disorders. The examiner found that the Veteran’s PTSD exhibited occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to the following symptoms: depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbances in motivation and mood. The examiner reported that there were no other symptoms attributable to PTSD or any other mental disorder. The Veteran was found capable to manage his financial affairs. The examiner commented that the Veteran’s PTSD was “essentially unchanged from the last evaluation. The PTSD alone does not render him unable to seek and engage in substantial gainful employment.” In conjunction with the Veteran’s statements during the examination that he was rendered unable to work due to his back disability, the examiner found that the Veteran’s physical problems were the primary reason that he could not work at all. Private treatment records from April 2014 show that the Veteran was hospitalized and diagnosed under Axis I with the following: severe major depressive disorder, recurrent in nature, without psychotic features, as well as panic attacks/generalized anxiety disorder, and posttraumatic stress disorder. Further details of this hospitalization were provided by the Veteran during the June 2015 VA examination as discussed below. On VA examination in June 2015, the examiner continued the diagnosis for PTSD with no other mental health disorders. The examiner found that the Veteran’s PTSD exhibited occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Other behavioral observations by the examiner were that the Veteran was cooperative and adequately groomed, he was casually dressed, he had good rapport and eye contact, his speech was within normal limits, and he was tearful throughout the examination. The examiner reported that there were no other symptoms attributable to PTSD or any other mental disorder. The Veteran was found capable to manage his financial affairs. The Veteran was noted to still be married to his wife and had a “great” relationship with his immediate family. His other social relationships consisted of “old friends from childhood.” He told the examiner that he can only perform approximately three hours of active movement before he has to sit down in his recliner chair for the rest of the day. The examiner noted that the Veteran had a mental health incident in April 2014. The Veteran said he ended up committing himself and was hospitalized for 7 days with an additional two months of outpatient treatment. He denied any current visual or auditory hallucinations. He endorsed past suicidal/homicidal ideation, but did not have any current ideation and never had a plan or intent. The examiner remarked that the Veteran’s PTSD symptoms and impairment remained severe. The Veteran told the VA examiner that the major reason for his inability to work was due to physical problems. In addition, the examiner found that the Veteran’s PTSD caused difficulty in interacting with others as well as concentration difficulties, irritability, and fatigue would likely interfere with work performance. Furthermore, the examiner commented that the Veteran’s extreme psychological reactivity (e.g., tearful) to reminders of Vietnam may interfere with his ability to successfully complete job tasks and to interact with others in a work environment. VA treatment records throughout the period on appeal do not show that the Veteran’s psychiatric symptoms were so frequent disabling to impact occupational and social impairment beyond those described in the VA examinations. Based on the foregoing, the Board finds that the Veteran’s documented PTSD symptoms (e.g. depressed mood, anxiety, chronic sleep impairment, suspiciousness, mild memory loss, disturbances in motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting) were not demonstrated to be so frequent and disabling as to result in total occupational and social impairment. The evidence of record does not show the Veteran’s PTSD symptoms were frequent and disabling 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; memory loss for names of close relatives, own occupation, or own name. The VA examiners during this period did not find the Veteran’s symptoms interfere with his routine activities. His speech was not intermittently illogical, obscure, or irrelevant; at all times of record during this period, he was able to converse with the VA examiners in a clear, coherent manner. He did not exhibit near-continuous panic or depression that affected his ability to function independently, appropriately and effectively. While in line with the type of symptoms involved for a 70 percent rating, the Veteran did previously endorse suicidal ideation; however, the record shows that he repeatedly denied any actual intent or plan. The medical evidence of record during this time found the Veteran was able to maintain his personal hygiene, finances, and household without assistance. Throughout the period on appeal, the evidence of record more closely approximates the criteria used to warrant a 70 percent rating. The Veteran was awarded a TDIU effective April 3, 2014, based on an increased severity for PTSD symptoms in which he was shown to be unable to adapt to stressful situations, including work or a work-like setting. Nonetheless, the Board finds that the evidence of record during the rating period on appeal does not demonstrate total social impairment as required for a schedular 100 percent rating under Diagnostic Code 9411. As discussed above, the Veteran has maintained that he continues to be married to his wife and has a “great” relationship with his immediate family. His other social relationships consisted of old friends from childhood and the Veteran indicated that his friends visited him at home. Moreover, prior to April 3, 2014 (i. e., the grant of a TDIU), the Veteran only endorsed being unable to work due to his nonservice-connected musculoskeletal disabilities, as corroborated by the November 2011 and March 2013 VA examinations. This contention of a total disability rating is also part of the remand discussed below this decision. Most notably, all the VA examiners during the appeal period found that the Veteran’s overall psychiatric symptoms were not so frequent and disabling to result in total occupational and social impairment and none of the VA examiners prior to June 2015 ruled out the Veteran’s ability to maintain substantially gainful employment due to the service-connected PTSD. Furthermore, the June 2015 VA examiner also only used speculative terms in discussing the impact of the Veteran’s PTSD symptoms on occupational and social impairment. The Board has considered the Veteran’s statements of record during the appeal that a higher disability rating is warranted for his psychiatric disability. The Veteran is competent to report symptomatology relating to his PTSD because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, the Board finds that the question of the severity of his PTSD is medically complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). To the extent that the Veteran alleges greater severity, the Board finds that the probative value of his allegations is outweighed by the aforementioned examiners’ findings that were made during the period of the appeal. Competent evidence concerning the nature and extent of the Veteran’s disability has been provided by the VA examiners during the period of the appeal and provided relevant medical findings in conjunction with the examinations. In this regard, the medical findings (as provided in the examination reports) directly address the evaluation criteria for this disability. Accordingly, the Board concludes that the Veteran’s PTSD was 70 percent disabling, but no higher, for the entire appeal period. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Right hand disability, left hand disability, low back disability, cervical spine disability, right shoulder disability, left leg disability, and a skin disability The veteran has current diagnoses of cervical stenosis, status post fusion, status post left knee arthroplasty, right shoulder rotator cuff tear/labral tear/glenohumeral arthritis/acromioclavicular degenerative hypertrophy, multilevel degenerative disc and facet disease of the lumbar spine, bilateral hand arthritis, and peripheral neuropathy of the bilateral upper and lower extremities; however, service treatment records are negative for hand, back, neck, right shoulder, or left leg conditions. In a November 2011 statement, the Veteran explained that he injured his shoulder and back in the helicopter incident. He also said that he has received injections to alleviate pain in his right shoulder, back, toes, and hands since 1969. Unfortunately, the Veteran said that these private treatment records were destroyed in 2005 due to Hurricane Katrina. Nonetheless, VA examinations should be scheduled as the Board cannot make a fully-informed decision on the issues of a right hand disability, left hand disability, low back disability, cervical spine disability, right shoulder disability, and left leg disability because no VA examiner has opined whether they are related to service. In disability compensation claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the factor of a relationship between a current disability and service (or, by analogy, to a service-connected disability), the Court has indicated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and a veteran’s service. The types of evidence that “indicate” that a current disability “may be associated” with military service include, but are not limited to, medical evidence that suggests a nexus, but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83; see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (while there must be “medically competent” evidence of a current disability, “medically competent” evidence is not required to indicate that the current disability may be associated with service). The Veteran received VA examinations for his skin disability in November 2011 and June 2015; however, these examinations contain inadequate medical opinions because neither answered the question of whether the Veteran’s skin disability is related to herbicide agent exposure. Furthermore, none of the medical opinions discuss whether the current diagnoses are related to or represent a progression of the diagnoses rendered during service. Once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In addition, these VA examination medical opinions failed to provide an adequate rationale to support each conclusion or discuss the contrary evidence associated with the record that supports the Veteran’s claims. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (a medical opinion must “support its conclusion with an analysis that the Board can consider and weigh against contrary opinions[;]” see also Nieves–Rodriguez, 22 Vet. App. 295, 304 (2008) (concluding that a medical opinion is not entitled to any weight if it does not contain a rationale that adequately connects data and conclusions). Without further clarification, the Board is without medical expertise to determine the nature and etiology of the claimed disabilities. Colvin v. Derwinski, 1 Vet. App. 171 (1991). 2. TDIU prior to April 3, 2014 The Veteran filed claims for TDIU that were received by VA in May 2011 and June 2011. The claims were based on nonservice-connected bone degeneration for the back, legs, knee, shoulder, hands, wrist, and feet. The Board notes that the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities prior to April 3, 2014, cannot be adjudicated until the service connection issues are addressed because they are intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left and right hand disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s right and left hand disorders are related to an in-service injury, event, or disease. (b.) State whether it at least as likely as not that the Veteran’s right and left hand disorder (1) began during active service, (2) manifested within one-year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any low back disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s low back disorder is related to an in-service injury, event, or disease. (b.) State whether it is at least as likely as not that the Veteran’s low back disorder (1) began during active service, (2) manifested within one-year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cervical spine disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s cervical spine disorder is related to an in-service injury, event, or disease. (b.) State whether it is at least as likely as not that the Veteran’s cervical spine disorder (1) began during active service, (2) manifested within one-year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left leg disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s left leg disorder is related to an in-service injury, event, or disease. (b.) State whether it is at least as likely as not that the Veteran’s left leg disorder (1) began during active service, (2) manifested within one-year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right shoulder disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s right shoulder disorder is related to an in-service injury, event, or disease. (b.) State whether it is at least as likely as not that the Veteran’s right shoulder disorder (1) began during active service, (2) manifested within one-year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any skin disability. The examiner must opine on the following: (a.) State whether it is at least as likely as not that the Veteran’s skin disorder is related to an in-service injury, event, or disease, including treatment for acne vulgaris, tinea versicolor, or any other rashes. The examiner should discuss whether any skin diagnosis rendered at any time during the appeal period are at least a likely as not related to and/or represent a progression of any diagnosis rendered during service. (b.) State whether it is at least as likely as not that the Veteran’s skin disorder is related to in-service herbicide agent exposure, to include chloracne or other acneform disease consistent with chloracne. (c.) The VA examiner is requested to provide a rationale for any opinion provided. 7. Then, readjudicate the claims on appeal. ROMINA CASADEI Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Connally, Counsel