Citation Nr: 18154887 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 15-10 831 DATE: December 4, 2018 ORDER Entitlement to service connection for a bilateral elbow disability is denied. Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for chronic chest pain is denied. Entitlement to an initial rating in excess of 30 percent for service-connected oral facial injury with loss of teeth, status-post root canal is denied. Entitlement to an initial compensable rating for service-connected bilateral hearing loss is denied. REMANDED Entitlement to a rating in excess of 10 percent prior to August 9, 2017 and in excess of 20 percent thereafter for service-connected degenerative disc disease (DDD) of the thoracolumbar spine is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected right eye disability is remanded. FINDINGS OF FACT 1. The probative medical evidence of record does not show that the Veteran has ever been diagnosed with a bilateral elbow disability, bilateral ankle disability, or disability manifested by chest pains throughout the period of appeal. 2. The Veteran’s dental injury has only been manifested by a loss of the maxilla less than 25 percent and replaceable by prosthesis without any showings of malunion or non union throughout the period of appeals. 3. The Veteran’s bilateral hearing loss has been manifested by auditory acuity levels of no worse than Level I impairment in the right ear and Level II impairment in the left ear throughout the period of appeals CONCLUSIONS OF LAW 1. A bilateral elbow disability, bilateral ankle disability, and disability manifested by chest pains were not incurred in active military service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303 (2017). 2. The criteria for an initial rating in excess of 30 percent for service-connected oral facial injury with loss of teeth, status-post root canal have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.150, Diagnostic Code 9915 (2017). 3. The criteria for an initial compensable rating for service-connected bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.85, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1991 to May 1991 and November 2000 to September 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Veteran was scheduled to appear in Washington D.C. for a personal hearing before a Veterans Law Judge; however, he withdrew his request for a hearing pursuant to 38 C.F.R. § 20.704 (e). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). Service connection may also be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303 (d). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303 (a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In each case where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such Veteran’s service as shown by such Veteran’s service record, the official history of each organization in which such Veteran served, such Veteran’s treatment records, and all pertinent medical and lay evidence. See 38 U.S.C. § 1154 (a). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107 (a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C. § 5107 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that “the tie goes to the runner.” Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. 1. Bilateral Elbows, Bilateral Ankles, and Chest Pains The Veteran contends that he currently suffers from disabilities of the bilateral elbows, bilateral ankles, and chest pains. A review of the Veteran’s service treatment records was absent for any discussion of disabilities of the bilateral elbows and bilateral ankles. Although there was a discussion of complaints of tightness in the chest in 2003, no formal diagnosis of any underlying conditions was made. A review of the Veteran’s post-service outpatient treatment records shows that he has been intermittently treated for complaints of bilateral elbow pain, bilateral ankle pain, and atypical chest pain. Testing has revealed no abnormalities resulting in any of these conditions. The Veteran has not been provided with any formal diagnoses for these conditions other than mere pain alone. There has been no indication of any functional impairment resulting from any reported bilateral elbow pain, bilateral ankle pain, and atypical chest pain. The Veteran was provided with a general VA examination in January 2012. At the examination, the Veteran complained of a history of bilateral elbow pain, bilateral ankle pain, and atypical chest pain. The examiner noted that the Veteran had a history of such complaints in prior outpatient treatment records, but no established diagnoses and no showings of any such complaints in service treatment records. Upon a review of the claims file, subjective interview, and objective testing, the VA examiner found that the Veteran did not have any current diagnoses for the bilateral elbows, bilateral ankles, or any underlying condition responsible for chest pains. Although pain was noted in each of these conditions, no indication of any functional impairment resulting from any reported bilateral elbow pain, bilateral ankle pain, and atypical chest pain was shown. Additionally, it is noted that, despite the Veteran’s 2003 complaints of chest tightness in service, it was found to be unrelated to exertion, as he had an all-normal stress test. Rather, the examiner felt that such symptom may be a manifestation of the Veteran’s already service-connected gastroesophageal reflux disease (GERD) and/or bronchitis as opposed to any separate and distinct pathology. The threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability, in this matter a diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement in a claim of service connection of current disability “is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary’s adjudication of the claim.” See McClain v. Nicholson, 21 Vet. App. 319 (2007). Here, the totality of the competent evidence does not reflect that the Veteran has or has had a diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain during the relevant period on appeal. Rather, with regard to the bilateral elbows and bilateral ankles, the Veteran merely had post-service findings of pain alone without any showing of any resulting functional impairment. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has recently found that pain alone can be a disability. Specifically, in Saunders v. Wilkie, No. 2017-1466 (Fed. Cir. Apr. 3, 2018) the Federal Circuit held that the term “disability” as used in 38 U.S.C. 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability.” In other words, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. The Federal Circuit did emphasize that they were not holding a veteran could demonstrate service connection “simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that her pain reaches the level of functional impairment of earning capacity.” In other words, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. However, the Board finds that, in accordance the holding in Saunders, the Veteran’s bilateral elbow pain and bilateral ankle pain does not rise to the level of a disability as there has been no showing of more than subjective pain and no resulting functional impairment during the period of the appeal. Therefore, no current diagnosed disabilities exist with regard to these two conditions. In regard to the Veteran’s chest pain, again in accordance with the holding in Saunders, there has been no showing of more than subjective pain and no resulting functional impairment during the period of appeals. Additionally, it appears, as suggested by the opinion of the January 2012 VA examiner, that the Veteran’s chest pain may actually be a symptom attributable to one of the Veteran’s already service-connected GERD and/or bronchitis. In any event, the complaints of chest pain are certainly not the result of any separately diagnosed disability. A review of current medical evidence since the filing of the Veteran’s claims does not show any relevant current diagnosis for any of the aforementioned claimed disabilities. Last, the Board notes that the Veteran is competent to testify as to a condition within his knowledge and personal observation. Barr v. Nicholson, 21 Vet. App. 303, 308-310 (2007). However, it is clear, based on a detailed review of the statements overall, that the Veteran has no actual specialized knowledge of medicine in general, or cardiology, pulmonology, gastroenterology, or orthopedics more particularly, and that he is merely speculating as to whether he has a current diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain. In this regard, he is not competent to diagnose such disabilities, as they require specialized medical knowledge and specific testing. See 38 C.F.R. § 3.159 (stating that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As such, the Veteran’s statements to the effect that he has a current diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain are lacking in probative value. Therefore, the most probative evidence of record reflects that the Veteran lacks a diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain during the appeals period. Absent the required diagnosis of a disability manifested by bilateral elbow pain, bilateral ankle pain, or chest pain at any time during the appeals period, there is no current disability to attribute to the Veteran’s military service. Brammer, 3 Vet. App. at 223. For the reasons provided above, the preponderance of evidence is against the Veteran’s claim. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulation. Gilbert, 1 Vet. App. at 49; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board notes that where, as in the present case, the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence ‘used to decide whether an original rating on appeal was erroneous.’ Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, ‘staged’ ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126. When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). 2. Dental The Veteran’s service-connected dental trauma is rated as 30 percent disabling in accordance with the General Rating Formula for Dental and Oral Conditions. 38 C.F.R. § 4.150, Diagnostic Code 9915. In particular, the Veteran’s condition is rated for criteria involving the maxilla, as prior examinations have revealed such to be the primary affected area. A 30 percent rating is warranted for a loss of 25 percent to 50 percent of the maxilla that is replaceable by prosthesis. Id. A 40 percent rating is warranted for a loss of 25 percent to 50 percent of the maxilla that is not replaceable by prosthesis. Id. Under Diagnostic Code 9914, a 50 percent rating is warranted for a loss of more than 50 percent of the maxilla that is replaceable by prosthesis. A 100 percent rating is warranted for a loss of more than 50 percent of the maxilla that is not replaceable by prosthesis. Id. Under Diagnostic Code 9916, a 30 percent rating is warranted for a showing of malunion or non union of the maxilla that results in sever displacement. Under Diagnostic Code 9913, a 30 percent rating is warranted for a loss of all of the lower teeth or loss of all of the upper teeth, where the lost masticatory surface of the maxilla cannot be restored by suitable prosthesis. A 40 percent rating is warranted for a loss of all of the teeth, where the lost masticatory surface of the maxilla cannot be restored by suitable prosthesis. Id. Under Diagnostic Code 9900, a 100 percent rating is warranted for chronic osteomyelitis or osteoradionecrosis of the maxilla. The Veteran contends that his service-connected dental trauma is worse than currently reflected by his evaluation of 30 percent. A review of the Veteran’s service treatment records reveals that the Veteran was treated extensively in service for oral and dental trauma, resulting in a loss of a portion of his maxilla and 3 corresponding teeth from July 2003 to December 2004. The Veteran was provided with prosthesis for correction. A review of the Veteran’s outpatient treatment records reveals that the Veteran has continued to be followed for his dental trauma. There have been no showings of loss of all of his teeth on either the lower or upper jaw, a loss of more than 50 percent of the maxilla, or that his condition is not able to be addressed with prosthesis. The Veteran was provided with a VA examination in January 2012. At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with loss of a portion of the maxilla and a loss of teeth. The loss of the maxilla was ascertained to be less than 25 percent and that it was replaceable by prosthesis. Missing teeth were noted as 9 and 10 of the upper jaw. It was also noted that the Veteran had developed a separate condition of temporomandibular joint (TMJ) disorder (a condition for which he is now separately compensated) as a result of treatment for his dental condition. There were no reported effects on the Veteran’s occupational functioning or activities of daily living. The Veteran was provided with an additional VA examination in August 2017. At the examination, upon a review of the claims file, subjective interview, and objective testing, the Veteran was diagnosed with loss of teeth and status post root canal. The Veteran had received an implant in the area of 13. The Veteran had a loss of the maxilla that was ascertained to be less than 25 percent and that it was replaceable by prosthesis. It was also noted that the Veteran had developed a separate condition of temporomandibular joint (TMJ) disorder (a condition for which he is now separately compensated) as a result of treatment for his dental condition. There were no reported effects on the Veteran’s occupational functioning or activities of daily living. Based on the above, the Board finds that the Veteran’s dental trauma only meets the criteria for a 30 percent evaluation throughout the entire appeal period. The Veteran’s condition would actually warrant less than 30 percent as shown by current examinations, as his trauma only resulted in the loss of less than 25 percent of his maxilla and a 30 percent evaluation requires at least 25 to 50 percent loss. However, the Board shall not disturb the 30 percent rating provided by the RO and it will remain intact. In order to warrant higher evaluations, the Veteran’s condition would need to show 50 percent or more loss of the maxilla, loss of all of his teeth, or the unsuitability of the use of prosthesis. As none of these conditions have been shown at any time during the current period of appeal, entitlement to higher evaluations are not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 49. The evidence of record does not warrant ratings in excess of those assigned for the Veteran’s hearing loss at any time during the period pertinent to this appeal. 38 U.S.C. § 5110 (2012); see also Fenderson, 12 Vet. App. at 126. 3. Bilateral Hearing Loss The Veteran’s bilateral hearing loss is rated as 0 percent disabling under the diagnostic code for hearing loss in accordance with the General Rating Formula for Impairment of Auditory Acuity. 38 C.F.R. § 4.85, Diagnostic Code 6100. The severity of hearing loss is determined by comparison of audiometric test results with specific criteria. Id. Ratings of defective hearing range from 0 percent to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. Id. The Schedule allows for audiometric test results to be translated into a numeric designation ranging from Level I to Level XI, for profound deafness, to rate the degree of disability from bilateral service-connected defective hearing. Id. The ratings derived from the Schedule are intended to make proper allowance for improvement by hearing aids. Id. In certain situations, the rating criteria provide for rating exceptional patterns of hearing impairment. If the puretone threshold is greater than 55 decibels at each of four specified frequencies (1000, 2000, 3000, and 4000 Hertz), VA must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. If the puretone threshold is 30 decibels or less at 1000 Hertz and simultaneously 70 decibels or more at 2000 Hertz, VA must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral and then elevate that numeral to the next highest numeral for consideration. Each ear is evaluated separately. 38 C.F.R. § 4.86. The Veteran contends that his bilateral hearing loss is worse than reflected by his current noncompensable evaluation. A review of the Veteran’s service treatment records shows that he was treated in service for bilateral sensorineural hearing loss. The Veteran’s last audiogram was provided in September 2010. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 20 55 55 LEFT 15 5 25 50 60 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 96 percent in the left ear. Audiogram revealed mild to severe sensorineural hearing loss for the right ear and mild to profound sensorineural hearing loss for the left ear. The examiner opined that a relationship between the Veteran’s current hearing impairment and military noise exposure would require mere speculation. In support the examiner provided that the whisper test conducted in the military was inadequate for showing high frequency hearing loss, the type most commonly associated with acoustic trauma. The Veteran was provided with a VA examination in January 2012. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 50 55 LEFT 10 5 25 55 55 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 94 percent in the left ear. Audiogram revealed sensorineural hearing loss bilaterally. It was noted that the Veteran’s bilateral hearing loss did not affect his occupational or daily life.   The Veteran was provided with an additional VA examination in August 2017. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 25 55 65 LEFT 15 15 45 55 55 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 84 percent in the left ear. Audiogram revealed sensorineural hearing loss bilaterally. It was noted that the Veteran’s bilateral hearing loss did not affect his occupational, but did affect his daily life in that he has difficulty hearing his wife and grandchildren. There were no other audiological results appropriate for VA purposes provided throughout the remaining period of appeals. Based on the above, the Board finds that the Veteran’s bilateral hearing loss only meets the criteria for a 0 percent evaluation throughout the entire appeal period. The Veteran’s bilateral hearing loss, as shown at service separation, is manifested by hearing impairment with a numeric designation of Level I in the right ear and Level I in the left ear. See 38 C.F.R. § 4.85, Diagnostic Code 6100. These level designations are taken by applying the average hearing loss in decibels for each ear (36 for the right ear and 25 for the left ear) to Table VIa, which is utilized when there are no speech discrimination values provided, as is the case here. Id. When those level designations are applied to Table VII, an evaluation of 0 percent is shown. Id. The Veteran’s bilateral hearing loss, as shown in his January 2012 VA examination, is manifested by hearing impairment with a numeric designation of Level I in the right ear and Level I in the left ear. See 38 C.F.R. § 4.85, Diagnostic Code 6100. These level designations are taken by applying the average hearing loss in decibels for each ear (33 for the right ear and 35 for the left ear) coupled with speech discrimination scores (96 for the right ear and 94 for the left ear) to Table VI, which is utilized when there are speech discrimination values provided, as is the case here. Id. When those level designations are applied to Table VII, an evaluation of 0 percent is shown. Id. The Veteran’s bilateral hearing loss, as shown in his August 2017 VA examination, is manifested by hearing impairment with a numeric designation of Level I in the right ear and Level II in the left ear. See 38 C.F.R. § 4.85, Diagnostic Code 6100. These level designations are taken by applying the average hearing loss in decibels for each ear (40 for the right ear and 43 for the left ear) coupled with speech discrimination scores (96 for the right ear and 84 for the left ear) to Table VI, which is utilized when there are speech discrimination values provided, as is the case here. Id. When those level designations are applied to Table VII, an evaluation of 0 percent is shown. Id. No other audiometric or speech discrimination values acceptable for VA purposes were shown in the Veteran’s private treatment records. The Veteran’s hearing has at no time shown evidence of any exceptional patterns of hearing as contemplated by the rating schedule. As such, the evidence of record does not reflect entitlement to an evaluation in excess of 0 percent for bilateral hearing loss. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 49. The evidence of record does not warrant ratings in excess of those assigned for the Veteran’s hearing loss at any time during the period pertinent to this appeal. 38 U.S.C. § 5110 (2012); see also Fenderson, 12 Vet. App. at 126. REASONS FOR REMAND 1. Lumbar spine The United States Court of Appeals for Veterans Claims (Court) has recently 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). Here the Veteran was provided with a VA examination for his lumbar spine in August 2017. At the examination, the examiner elicited information from the Veteran regarding his symptoms, to include indication that the Veteran experienced intermittent flare-ups. The Veteran described the pain during flare-ups as 10 on a scale of 1 to 10. However, the examiner did not ask the Veteran about any functional impairments that occur with such flare-ups or any other such characteristics that may occur with flare-ups, such as weakness, fatiguability, or incoordination. Despite this, the examiner opined that he could not discuss whether any pain, weakness, fatiguability, or incoordination that may occur with such flare-ups could limit the Veteran’s functional ability, as there is no conceptual or empirical basis for rendering such opinion without direct observation. The Board finds that the VA examiner’s opinion is not based upon a complete consideration of the facts as outlined by Sharp and that such deficiency frustrates the Board’s analysis of the Veteran’s disability during periods of flare-ups. Although the VA examiner stated that he could not provide an opinion regarding flare-ups without directly observing such, because it contravenes any conceptual or empirical basis, the Board finds that such opinion is premature without having elicited all of the pertinent facts, i.e. other characteristics associated with the Veteran’s flare-ups and the Veteran’s descriptions of functional limitations he may experience during such time periods. Certainly there may be both a conceptual and empirical basis to render an opinion regarding the effects of flare-ups on functionality if the examiner is provided with more factual background as has been previously noted by the Court in Sharp. As such, the Veteran should be afforded a new VA examination in which such information is obtained and properly considered in accordance with the Court’s holding in Sharp. A complete rationale for any opinions rendered must be provided. 2. Right Eye The Veteran was provided with VA examinations for his right eye in August 2017. At the examination, it was noted that the Veteran had the presence of a pre-operative cataract in his right eye in addition to his choroidopathy, keratopathy, and ptosis. Although, the examiner appeared to specifically attribute the choroidopathy, keratopathy, and ptosis to the Veteran’s service-connected right eye disability, such discussion was absent with regard to the cataract. Because the inclusion of such condition in the Veteran’s overall right eye disability may afford higher evaluations, the Board finds that an opinion regarding the relationship of the cataract to the service-connected right eye condition is necessary to the proper adjudication of the claim. As such, the claims file should be returned to the VA examiner who conducted the August 2017 VA eyes examination. If that examiner is no longer available, then the Veteran’s claims file should be forwarded to an examiner of like skill and qualification. Any necessary testing or examination should be conducted. The examiner should be asked to clarify whether the Veteran’s diagnosed pre-operative cataract is the result of his service-connected right eye disability or any other service-connected disability. If it is determined that the cataract is not a part of the Veteran’s service-connected right eye disability, then a discussion of exclusively attributable symptoms to the Veteran’s service-connected right eye disability should be provided. A complete rationale for any opinions rendered must be provided. Additionally, as this case must be remanded for the foregoing reasons, any recent treatment records, including VA records, should also be obtained. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records not already on file should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all outstanding VA treatment records. All attempts to procure records should be documented in the file. If the RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. After any additional evidence has been associated with the claims file, the Veteran should be afforded an appropriate examination in order to determine the current severity of his DDD of the thoracolumbar spine. The entire file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If this is not possible, the examiner must provide a detailed rationale as to why it is not. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran’s medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 3. The Veteran’s claims file should be returned to the VA examiner who conducted the August 2017 VA eyes examination. If that examiner is no longer available, then the Veteran’s claims file should be forwarded to an examiner of like skill and qualification. Any necessary testing or examination should be conducted. The examiner should be asked to clarify whether the Veteran’s diagnosed pre-operative cataract is the result of his service-connected right eye disability or any other service-connected disability. If it is determined that the cataract is not a part of the Veteran’s service-connected right eye disability, then a discussion of exclusively attributable symptoms to the Veteran’s service-connected right eye disability should be provided. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran’s medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 4. After completing the above, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran should be issued a supplemental statement of the case. An   appropriate period of time should be allowed for response. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Dodd, Counsel