Citation Nr: 18154972 Decision Date: 12/03/18 Archive Date: 12/03/18 DOCKET NO. 06-25 886 DATE: December 3, 2018 ORDER The claim of entitlement to service connection for cicatricial neuroma cutis, also claimed as headaches, is denied. REMANDED The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. The claim of entitlement to a rating greater than 10 percent for psoriasis is remanded. The claim of entitlement to a rating greater than 20 percent for degenerative disc disease, psoriatic thoracic, and lumbar spondyloarthropathy, is remanded. The claim of entitlement to special monthly compensation based on loss of use of a creative organ is remanded. FINDING OF FACT Although the Veteran had an in-service injury to the head, and currently has diagnoses of tension and migraine headaches, his headaches were not shown during service or for years after service, and the weight of the competent, credible, and probative evidence on the question of medical nexus to service weighs against the claim. CONCLUSION OF LAW The criteria for service connection for cicatricial neuroma cutis, also claimed as headaches, are not met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1991 to August 1998. This appeal to the Board of Veterans’ Appeals (Board) arose from January 2005, September 2012, and July 2013 rating decisions. The procedural history of this case is a lengthy one involving multiple actions by the Board and an appeal to and remand from the United States Court of Appeals for Veterans Claims (Court). As this procedural history has been detailed in the prior actions in the appeal, it will only be repeated herein as necessary to explain the state of the issues currently before the Board. Most recently, in June 2017, the matters currently on appeal were remanded for the Veteran to be afforded a Board hearing. In January 2018, the Veteran testified during a Board videoconference hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is of record. Notably, the hearing transcript reflects the Veteran’s desire to withdraw from appellate consideration the issues of entitlement to higher ratings for his service-connected lumbar spine and skin disabilities. However, it does not appear from the hearing transcript that the Veteran had full knowledge of the consequences of withdrawing his appeal as to those issues. See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018) (setting forth the standard for withdrawals of claims made during a hearing). In August 2018, the Board sent to the Veteran and his representative a letter explaining the consequences of withdrawing the appeal, and requested that the Veteran indicate in writing whether he still desired to withdraw his appeal as to the issues of entitlement to higher ratings for his service-connected lumbar spine and skin disabilities. The Veteran was informed that if no response was received within 30 days from the date of that letter, the Board would proceed to review all issues on appeal. No response was subsequently received. Accordingly, the issues of entitlement to higher ratings for the Veteran’s service-connected lumbar spine and skin disabilities remain on appeal. Service connection cicatricial neuroma cutis, also claimed as headaches Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in the line of duty. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The determination as to whether elements are met is based on an analysis of all the evidence of record, and evaluation of its competency, credibility and probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Baldwin v. West, 13 Vet. App. 1, 8 (1999). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence showing (1) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (2) present manifestations of the same chronic disease; or (b) when a chronic disease is not shown as such during service, by evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In the instant case, the Veteran contends that has a neuroma cutis or a headache disorder that is attributable to service. Specifically, the Veteran reports that while in service, he suffered a cranial blunt force trauma and that he developed headaches shortly thereafter, which have persisted since service. The Veteran’s service treatment records (STRs) include a May 1997 treatment entry noting a small laceration on the forehead sustained while the Veteran was opening the trunk of a car. During his January 2018 hearing, the Veteran reported that locking mechanism on the trunk had been damaged during an accident, and that, when he was able to open the trunk, it popped open with such force that he was thrown backwards, landing on his shoulder blades. The May 1997 treatment entry fails to indicate any complaints of pain or loss of consciousness and a July 1997 neuropsychological evaluation failed to suggest any traumatic brain injury (TBI). The Veteran’s May 1998 separation examination report is silent for any complaints of headaches or other residuals related to the May 1997 incident. Post-service treatment records show that the Veteran was examined by VA in February 1999, the report of which is silent for complaints of headaches. Treatment records are then silent for complaints of headaches until 2007. In August 2007, the Veteran reported a history of headaches, which were assessed as a mix of tension and migraine headaches. The Veteran was afforded a VA TBI examination in March 2015, the report of which fails to contain a diagnosis of TBI. Consideration was given to the May 1997 in-service incident, but the examiner found no evidence of a TBI. The Veteran was also afforded a VA headaches examination in March 2015, the report of which notes diagnoses of tension and migraine headaches, diagnosed in 2007. The examiner reviewed the Veteran’s STRs, noting the May 1997 incident, as well a December 1992 notation of tension headaches related to allergic rhinitis. The examiner recorded the Veteran’s history of having sustained an injury to head in service, when he was hit with the trunk of a car. The examiner indicated that the Veteran could not remember when his headaches began, but that the Veteran believed that the laceration to his forehead had severed nerves in that area, causing his headaches. A computed tomography (CT) brain scan was conducted as part of the examination, the report of which showed no intracranial disease process. Some asymmetry in the size of the lateral ventricles was seen, but was noted to likely be a normal variant. The examiner also reviewed the report of a magnetic resonance imaging (MRI) scan that was done in August 2006, noting that there was no evidence of acoustic neuroma or mass in the cerebellar pontine angle and that the seventh and eighth cranial nerves were normal in size and signal. Regarding the etiology of the Veteran’s migraine and tension headaches, the examiner opined that it was less likely than not the headaches were related to service, to include the May 1997 incident. As rationale for that opinion, the examiner noted that no headaches were indicated at the time of the May 1998 separation examination, which the examiner explained would not indicate an ongoing headache condition. The examiner explained that studies show that 96 percent of mild TBI headache symptoms develop within six months after the TBI and resolve within one year. The examiner also noted that the Veteran had not been diagnosed as having a TBI, and opined therefore, that is was less likely than not that any current headache condition was the result of a TBI. The examiner also found no evidence of a chronic headache condition existing since service, noting that the no headaches were noted at the time of separation from service or for many years thereafter. The examiner further explained that neuroma cutis is a relatively rare tumor involving nervous tissue of the skin. The examiner noted no existent medical evidence to support a diagnosis of neuroma cutis and also found no evidence of any ongoing issues related to the Veteran’s forehead scar. The examiner thus opined that it was less likely than not that the Veteran’s headaches are etiologically related to the Veteran’s scar that resulted from the May 1997 incident. Turning to whether the evidence warrants a grant of service connection in this case, the Board first finds that competent evidence establishes that the Veteran has a current headache disability, as well as a documented in-service injury. However, regarding the question of medical nexus—the matter upon which this claim turns—the Board finds that the evidence weighs against finding a medical relationship, or nexus, between the Veteran’s currently diagnosed tension and/or migraine headaches and his military service. In addressing the question of whether there exists a nexus between the Veteran’s current headache disability and service, the Board first points out that a chronic headache disability was not shown in service, or for many years thereafter. Here, the evidence of record first show treatment for headaches in 2007, nearly a decade after separation from service. Absent competent evidence indicating that the Veteran had a headache disability within one year of his separation from service, to the extent that the Veteran’s headaches can be considered an organic disease of the nervous system, service connection may not be awarded on a presumptive basis. The Board also points out that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor for consideration in determining whether the evidence support in-service incurrence of a disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Here such factor, when considered in light of the other probative evidence of record, tends to weigh against the claim. Although the Veteran has asserted that he has had headaches since service, the record is devoid of any evidence even suggesting a chronic headache disability prior to July 2007 when he was prescribed Zolmitriptan for headaches. Thus, even considering the in-service injury, there is no evidence that the Veteran sustained any chronic headache disability as a result of the injury. Indeed, the evidence weighs against a finding that the Veteran sustained a TBI and no headaches were noted at the time of the injury, upon exit from service, or until many years after service. The Veteran also told the VA examiner that he could not remember when his headaches started. For these reasons, the current assertions as to continuity of headache symptoms in and since service—which, as noted, are not consistent with the contemporaneous record—are not deemed credible, and, hence, are not persuasive. Furthermore, the only medical opinion addressing medical nexus to service is negative. As the VA examiner, in providing the March 2015 opinion, considered all pertinent evidence of record and provided a complete rationale, relying on and citing to the records reviewed, and offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to such opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). In this regard, the Board points out that the examiner engaged in a lengthy summary of the evidence reviewed, to include the lay evidence of record. The examiner also pointed out that the Veteran had no complaints of headache pain at separation from service, or when examined in February 1999. Moreover, there is no indication that the VA examiner failed to consider any piece of relevant evidence before providing the requested opinion. The Board also finds no reason to discount the medical opinion based on the VA examiner’s expertise and qualifications as a medical professional. Given the above, the Board simply finds no evidentiary basis upon which to establish service connection for cicatricial neuroma cutis or headaches, as a crucial element of service connection—nexus to service—has not persuasively been shown. Accordingly, the claim for service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Unfortunately, the Board finds that further action in regarding the claims for service connection for an acquired psychiatric disorder, for higher ratings for the Veteran’s lumbar spine disability and psoriasis, and for entitlement to special monthly compensation due to loss of use of a creative organ is warranted, even though such will, regrettably, further delay an appellate decision on these matters. As for the matter of entitlement to service connection for an acquired psychiatric disorder, that claim was remanded, for further development, in December 2014. Specifically, the Board remanded the matter for the Veteran to be afforded a VA examination to determine the etiology of any diagnosed psychiatric disorder, to include a determination as to whether the Veteran meets the diagnostic criteria for a diagnosis of PTSD. As to each diagnosed psychiatric disability, the Board instructed that the examining clinician provide an opinion as to whether it is as least as likely as not the claimed disability (1) is related to the Veteran’s active military service, (2) is proximately due to a service-connected disability, and/or (3) has been aggravated by a service-connected disability. A review of the record shows that the Veteran underwent a VA PTSD examination in March 2015. Regarding the requested opinions, the examiner found that that the Veteran did not meet the diagnostic criteria for a diagnosis of PTSD, but did diagnose several other psychiatric disorders, to include somatic symptom disorder and adjustment disorder. As to those disorders, the examiner opined that it is “less likely than not that any of the above given diagnoses are directly caused by or related to [the Veteran’s] military service or his service-connected conditions.” Although the examination report contains a lengthy discussion of the Veteran’s psychiatric history and explanation for why a diagnosis of PTSD is not supported, the opinion does not seem to address the likelihood that the Veteran has a psychiatric disability that has been aggravated by a service-connected disability. In this regard, the Board points out that secondary service connection is a two-part issue that involves analysis of both causation and aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that secondary service connection is a two-part issue that involves analysis of causation and analysis of aggravation); 38 C.F.R. § 3.310. Thus, because the VA examiner did not address the second element of secondary service connection, the March 2015 opinion report is inadequate for rating purposes. Remand of the Veteran’s claim for service connection for an acquired psychiatric disorder is therefore required for a new opinion, as set forth below. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand); 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). The Board also finds it necessary to remand the claim of entitlement to special monthly compensation due to loss of use of a creative organ, as that matter is intertwined with the issue of entitlement to service connection for an acquired psychiatric disorder. Indeed, when examined in September 2015, the VA examiner attributed the Veteran’s erectile dysfunction to the Veteran’s mental health condition, to include treatment of such condition. As such, the claim of entitlement to special monthly compensation due to loss of use of a creative organ is inextricably intertwined with the above claim for service connection that is being remanded, and they should be considered together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). Regarding the claim for a rating greater than 20 percent for the Veteran’s lumbar spine disability, the Board notes that the Veteran was last examined in connection with that disability in March 2015. Upon review of the report of that examination, the Board finds that it is inadequate to rely upon in this case. Specifically, the Board cannot discern from the report of the March 2015 VA examination whether the Veteran’s spine was tested for pain on both active and passive motion, in weight bearing and non-weight bearing. See 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158, 168 (2016) (holding “that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities”). Indeed, the examiner noted no evidence of pain with weight bearing, but then there is no indication that passive range of motion testing was done, nor does the examiner identify whether there is pain when the joint is used in non-weight bearing. The examiner also indicated objective evidence of pain with motion, to include on forward flexion and extension, but made no specific finding as to the degree of range-of-motion lost due to pain on use. Thus, it is unclear from the examination at what point the Veteran experienced painful motion. The United States Court of Appeals for Veterans Claims (Court) has found similar examination findings to be inadequate because the examiner did not explicitly report “whether and at what point during the range of motion the appellant experienced any limitation of motion that was specifically attributable to pain.” Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Court stressed that such a finding is important in providing a “clear picture of the nature of the veteran’s disability and the extent to which pain is disabling,” so as to “allow the Board to ensure that the disabling effects of pain are properly considered when evaluating any functional loss due to pain that is attributable to the veteran’s disability.” Id. Accordingly, the Board finds that the matter must be remanded for the Veteran to be afforded another VA compensation examination to more definitively assess the current severity of his service-connected lumbar spine disability. As for the Veteran’s psoriasis, the Veteran was last afforded a VA examination for evaluation of that disability in April 2013. The Board notes that since that time, the legal authority pertaining to the evaluation of skin disabilities has undergone a number of changes, specifically with regard to the definition of “systemic therapy” as used in the diagnostic criteria for evaluating disabilities of the skin. Notably, VA recently amended the criteria for rating the skin. Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, “systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.” DC 7816 continues to apply to psoriasis, but is rated under the general rating formula for the skin. However, as for the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the Court in Johnson v. McDonald, 27 Vet. App. 497, 505 (2016), held that use of a topical steroid constituted “systemic therapy” within the meaning of DC 7806. In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the United States Court of Appeals for the Federal Circuit (Federal Circuit) reversed this decision and determined that “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs” under DC 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, No. 16-2037, 2018 U.S. App. Vet. Claims Lexis 1314 (Sept. 28, 2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. Significantly, regarding the effective date of the new criteria, VA indicated in the Supplementary Information to the Final Rule that its “intent is that the 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.” The Veteran’s claim in this case was pending prior to the August 13, 2018, effective date of the new criteria, and therefore, evaluation of the Veteran’s disability requires consideration of both the old and new criteria. However, the Federal Circuit’s interpretation of the term “systemic therapy” in the old criteria applies throughout the entire period prior to the August 13, 2018, effective date of the new criteria. Rivers v. Roadway Express, 511 U.S. 298, 312-13 (1994) (“[j]udicial construction of a statute [or regulation] is an authoritative statement of what the statute [or regulation] meant before as well as after the decision of the case giving rise to that construction”); Jordan v. Nicholson, 401 F.3d 1296, 1298-99 (Fed. Cir. 2005) (a new interpretation of a statute retroactively affects decisions still open on direct review); Threatt v. McDonald, 28 Vet. App. 56, 63 (2016) (noting the “normal principle at this Court that judicial decisions operate retrospectively”). Overall, the Board finds that the medical evidence of record is inadequate for the Board to determine whether, at any point during the pendency of the claim, the Veteran’s use of a topical corticosteroid treatment, to include hydrocortisone as noted in the Veteran’s medical records, could meet the definition of “systemic therapy” discussed above. See Colvin v. Derwinski, 1 Vet. App. 191, 175 (1999) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). The Board also notes that since last examined in April 2013, the Veteran has presented with complaints of worsening psoriasis. Given the suggestion that the Veteran’s disability may have worsened since last examined, the Board finds that a new examination is also necessary to obtain more contemporaneous findings assess the severity of the service-connected skin disability. See 38 U.S.C. § 5103A; Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). See also 38 C.F.R. § 3.327 (a) (duty to provide a thorough and contemporaneous examination is triggered when the “evidence indicates there has been a material change in a disability or that the current rating may be incorrect”). The Veteran is hereby notified that failure to report to any scheduled examination(s), without good cause, may well result in denial of his claims—in particular, the increased rating claim(s). See 38 C.F.R. § 3.655(a), (b). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and that the record with respect to all claims is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file includes records of the Veteran’s treatment at the VA Medical Center (VAMC) in Shreveport, Louisiana, dated through September 2015. However, more recent records from this facility may exist. As such, the AOJ should obtain all outstanding VA records dated since September 2015, following the provisions of 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the remaining claims on appeal, explaining that he has a full one-year period to respond. See 38 U.S.C. § 5103(b)(1). But see 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the remaining claims on appeal. Adjudication of each higher rating claim should include consideration of whether staged rating of the disability—assignment of different ratings for distinct periods of time, based on the facts found—is appropriate. The matters are hereby REMANDED for the following action: 1. Obtain from the VAMC in Shreveport, Louisiana, all outstanding records of evaluation and/or treatment of the Veteran, since September 2015. Follow the procedures of 38 C.F.R. § 3.159 for requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to any remaining claim(s) on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from any contacted entity have been associated with the claims file, arrange to obtain an addendum medical opinion by the VA examiner who examined the Veteran in March 2015 in connection with his claim for service connection for an acquired psychiatric disorder. If that individual is not available, document that fact in the record, and arrange to obtain an addendum opinion from an appropriate physician based on claims file review (if possible). Only arrange for the Veteran to undergo examination if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the addendum opinion/examination report should reflect consideration of the Veteran’s documented medical history and assertions. With respect to each of the Veteran’s diagnosed psychiatric disorders, the physician should provide an opinion, consistent with sound medical principles, and based on full consideration of the Veteran’s medical history, assertions, and supporting evidence provided, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any diagnosed disorder was caused OR is or has been aggravated (worsened beyond the natural progression) by a service-connected disability. The physician must address both causation and aggravation. If aggravation is found, the physician should attempt to quantify the extent of additional disability resulting from aggravation, to include by identifying, to the extent possible, the baseline level of disability prior to aggravation. In addressing the above, the physician must consider and discuss all pertinent medical and other objective evidence, as well as all lay assertions. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. Complete, clearly-stated rationale for the conclusions reached must be provided. The physician is reminded that merely stating that it is his or her opinion that a psychiatric condition was not caused or aggravated by a service-connected disability is not sufficient. An explanation is required that takes into account the record and pertinent medical principles and the physician’s rationale should include citation to pertinent evidence and/or medical principles relied upon to form that opinion. 5. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA spine examination by an appropriate medical professional. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all results furnished to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should conduct range of motion testing of the thoracolumbar spine (reported in degrees). Specifically, the examiner should test the range of motion in active motion, passive motion, weigh bearing, and non-weight bearing (as appropriate). 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 so state, and explain why. In conducting range of motion testing, the examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner should indicate the point at which motion limiting pain begins. In addition, if the examination is not conducted during a flare-up, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss in the lumbar spine due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. The examiner should specifically indicate whether there is any ankylosis. The examiner should provide a complete assessment of the severity of the Veteran’s service-connected back disability, to include consideration of functional effects due to severe pain. All examination findings/testing results, along with a complete, clearly-stated rationale for the conclusions reached, must be provided. 6. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA skin examination by an appropriate medical professional. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all results furnished to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should specify all symptoms and functional impairment associated with the skin. The nature and severity of such symptomatology should be described in detail. Following examination, the examiner should render specific clinical findings as to the percentage of the total area of the body affected by the service-connected disability, as well as the percentage of the exposed areas affected. If the examination must take place during an inactive stage of disability, separate percentages based on a review of the record and the Veteran’s description of his symptoms during a period of exacerbation should be provided. The examiner should also indicate whether, at any point since January 2004, the Veteran’s psoriasis has required treatment with systemic therapy such as corticosteroids or other immunosuppressive drugs and should identify the total duration of such required treatment during the relevant time period. In this regard, the examiner should consider the definitions of “systemic therapy” as described by the Court and the Federal Circuit to include meaning “treatment pertaining to or affecting the body as a whole.” If the examiner finds that the Veteran has been treated only with a topical corticosteroid, the examiner should explain whether such topical application can be considered to have affected the body as a whole, which should include discussion of the method by which the treatment works and its side effects. Based on a review of all pertinent evidence and lay assertions, the examiner should also indicate whether, at any point since January 2004, the Veteran’s service-connected skin disability has increased in severity, and, if so, the approximate date(s) of any such change(s), the extent of severity of disability at each stage (to include identification of the total duration of any required treatment with systemic therapy such as corticosteroids or other immunosuppressive drugs during any such stage). All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 7. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 8. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claims on appeal. considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority (to include, for each increased rating claim, consideration of whether staged rating for the disability is appropriate). JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Neilson, Counsel