Citation Nr: 18158556 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 13-11 532 DATE: December 18, 2018 ORDER New and material evidence not having been received, the application to reopen the claim of entitlement to service connection for right ear hearing loss is denied. New and material evidence having been received, the claim of entitlement to service connection for a left elbow disorder is reopened; the appeal is granted to this extent only. New and material evidence not having been received, the application to reopen the claim of entitlement to service connection for bilateral ankle disorder is denied. New and material evidence having been received, the claim of entitlement to service connection for fibromyalgia is reopened. Service connection for fibromyalgia is granted. Service connection for chronic fatigue syndrome is granted. An initial rating in excess of 10 percent for limitation of adduction of the right hip is denied. The separate rating for limitation of extension of the right hip, evaluated as noncompensably disabling as of January 31, 2018, is proper; the appeal is denied. The separate rating for limitation of flexion of the right hip, evaluated as noncompensably disabling as of January 31, 2018, is proper; the appeal is denied. A compensable rating for left ear hearing loss is denied. REMANDED Entitlement to service connection for a left elbow disorder is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected back disability, is remanded. Entitlement to service connection for hypertension, claimed as secondary to service-connected disability, is remanded. Entitlement to a rating in excess of 10 percent for residuals of cerebrovascular accident (CVA) is remanded. Entitlement to an initial rating in excess of 10 percent prior to September 28, 2017, and in excess of 40 percent thereafter for thoracolumbar spine degenerative disc disease is remanded. Propriety of the separate rating assigned for radiculopathy of the right lower extremity, evaluated as 10 percent disabling as of February 24, 2016, is remanded. Propriety of the separate rating assigned for surgical scar of the lower back, evaluated as noncompensably disabling as of April 6, 2016, is remanded. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an effective date prior to March 6, 2017, for the award of a 50 percent rating for PTSD is remanded. Entitlement to an initial compensable rating for eczema is remanded. FINDINGS OF FACT 1. In a final decision issued in June 2008, the Agency of Original Jurisdiction (AOJ) denied service connection for right ear hearing loss. 2. Evidence added to the record since the final June 2008 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for right ear hearing loss. 3. In a final decision issued in September 2011, the AOJ determined that new and material evidence had not been received to reopen a claim of entitlement to service connection for a left elbow disorder. 4. Evidence added to the record since the final September 2011 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a left elbow disorder. 5. In a final decision issued in May 2014, the AOJ denied service connection for a bilateral ankle disorder and fibromyalgia. 6. Evidence added to the record since the final May 2014 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a bilateral ankle disorder. 7. Evidence added to the record since the final May 2014 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for fibromyalgia. 8. The Veteran had service in the Southwest Asia theater of operations. 9. Resolving all doubt in the Veteran’s favor, fibromyalgia manifested to a degree of 10 percent or more not later than December 31, 2021. 10. Resolving all doubt in the Veteran’s favor, chronic fatigue syndrome manifested to a degree of 10 percent or more not later than December 31, 2021. 11. For the entire appeal period, the Veteran’s right hip disability is manifested by abduction limited to, at most, 25 degrees, extension limited to, at most, 10 degrees, and flexion limited to, at most, 60 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups, without ankylosis, flail joint, or impairment of the femur. 12. For the entire appeal period, the Veteran’s service-connected left ear hearing loss resulted in no worse than Level I hearing acuity. CONCLUSIONS OF LAW 1. The June 2008 rating decision that denied service connection for right ear hearing loss is final. 38 U.S.C. § 7105(c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2007) [(2017)]. 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for right ear hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The September 2011 rating decision that determined that new and material evidence had not been received to reopen a claim of entitlement to service connection for a left elbow disorder is final. 38 U.S.C. § 7105(c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2011) [(2017)]. 4. New and material evidence has been received to reopen the claim of entitlement to service connection for a left elbow disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The May 2014 rating decision that denied service connection for a bilateral ankle disorder and fibromyalgia is final. 38 U.S.C. § 7105(c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2013) [(2017)]. 6. New and material evidence has not been received to reopen the claim of entitlement to service connection for a bilateral ankle disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 7. New and material evidence has been received to reopen the claim of entitlement to service connection for fibromyalgia. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 8. The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 9. The criteria for service connection for chronic fatigue syndrome have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.17. 10. The criteria for an initial rating in excess of 10 percent for limitation of adduction of the right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 11. The separate rating for limitation of extension of the right hip, evaluated as noncompensably disabling as of January 31, 2018, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 12. The separate rating for limitation of flexion of the right hip, evaluated as noncompensably disabling as of January 31, 2018, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 13. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to July 1986 and July 1992 to May 2008, to include service in Southeast Asia, and with additional service in the Army National Guard. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in May 2010, August 2017, September 2017, and November 2017 by a Department of Veterans Affairs (VA) Regional Office. In September 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge concerning the issues of entitlement to increased ratings for his back disability, right hip disability, and eczema. A transcript of the hearing is of record. The Veteran has not requested a Board hearing in connection with the remaining issues on appeal. In December 2015, the Board remanded the issues of entitlement to increased ratings for the Veteran’s back disability, right hip disability, and eczema. In December 2017, the Board denied an initial compensable rating for eczema and again remanded the remaining claims. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). Pursuant to an August 2018 Joint Motion for Partial Remand, the Court vacated the December 2017 Board decision to the extent that denied entitlement to an initial compensable rating for eczema and remanded the issue to the Board. With regard to the previously remanded issues of entitlement to increased ratings for back and right hip disabilities, an April 2018 rating decision granted an increased rating of 40 percent as of September 28, 2017, for the Veteran’s back disability, and assigned separate ratings for radiculopathy of the right lower extremity, evaluated as 10 percent disabling as of February 24, 2016; surgical scar of the lower back, evaluated as noncompensably disabling as of April 6, 2016; limitation of extension of the right hip, evaluated as noncompensably disabling as of January 31, 2018; and limitation of flexion of the right hip, evaluated as noncompensably disabling as of January 31, 2018. While the Veteran entered a notice of disagreement as to the propriety of the initially assigned ratings in September 2018, the Board finds that such issues are part and parcel of the Veteran’s claims for increased ratings for his back and right hip disabilities. Therefore, the Board has assumed jurisdiction over such matters and they are included on the title page of this decision. The Board further observes that, while additional evidence has been associated with the record since the AOJ’s most recent adjudication of the Veteran’s claims, such is either irrelevant or duplicative of the evidence previously considered in regard to the claims denied herein. 38 C.F.R. § 20.1304(c). Therefore, there is no prejudice to him in the Board proceeding with an adjudication of such claims at the present time. Furthermore, as the Board’s decision to reopen the Veteran’s claims for service connection for left elbow disorder and fibromyalgia, and grant service connection for fibromyalgia and chronic fatigue syndrome, are fully favorable, there is likewise no prejudice to the Veteran in the Board taking such actions. Finally, as the remainder of the claims are being remanded, the AOJ will have an opportunity to consider such evidence in the readjudication of such matters. New and Material Evidence In rating decisions issued in June 2008, September 2011, and May 2014, the AOJ denied service connection for right ear hearing loss, determined that new and material evidence had not been received in order to reopen a claim of entitlement to service connection for a left elbow disorder, and denied service connection for a bilateral ankle disorder and fibromyalgia, respectively. In those same months, the Veteran was advised of the decisions and his appellate rights; however, he did not enter a notice of disagreement as to such decisions. Additionally, no new and material evidence was physically or constructively received within one year of the issuance of such decisions, and no relevant service department records have since been received. Therefore, the rating decisions are final. 38 U.S.C. § 7105(c) (West 2002) [(2012)]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2007), (2011), (2013) [(2017)]. Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. See Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for right ear hearing loss. In the June 2008 rating decision, the AOJ considered the Veteran’s service treatment records, post-service treatment records, a February 2008 VA examination, and the Veteran’s lay statements, and denied service connection for right ear hearing loss based on the absence of a disability of right ear hearing loss as defined by VA regulations. In this respect, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Since the issuance of the June 2008 rating decision, additional evidence consisting of VA and private treatment records, VA examination reports, and the Veteran’s lay statements has been received. As the evidence does not reflect a current disability of right ear hearing loss as defined by VA regulations, which was the basis of the prior denial, the Board finds that the evidence added to the record since the prior denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the claim of entitlement to service connection for right ear hearing loss. Consequently, new and material evidence has not been received to reopen the claim. 2. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a left elbow disorder. In the September 2011 rating decision, the AOJ considered the June 2008 rating decision that originally denied the claim for service connection for a left elbow disorder, to include all evidence considered therein, and additional post-service treatment records, and denied the application to reopen the claim for service connection for a left elbow disorder based on the absence of a diagnosis of such disorder. Since the issuance of the decision, additional evidence consisting of VA and private treatment records, VA examination reports, and the Veteran’s lay statements have been associated with the record. In pertinent part, private treatment records reflect treatment for left elbow complaints and a March 2018 VA examination report reflects a diagnosis of triceps tendinitis. Upon review, the Board finds this diagnosis is new and directly addresses the missing element upon which the previous denial was based. Therefore, the evidence added to the record since the final September 2011 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a left elbow disorder. As such, new and material evidence has been received to reopen the claim of entitlement to service connection for left elbow disorder. 3. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a bilateral ankle disorder. In the May 2014 rating decision, the AOJ considered the Veteran’s service treatment records, post-service treatment records, a November 2013 VA examination, and the Veteran’s lay statements, and denied service connection for hypoactive left ankle and hypoactive right ankle as the competent evidence failed to show that such disorders were related to the Veteran’s service-connected back disability or otherwise related to his military service. Since the issuance of the May 2014 rating decision, additional evidence consisting of VA and private treatment records, VA examination reports, and the Veteran’s lay statements has been received. However, such evidence does not include a competent opinion relating the Veteran’s bilateral ankle disorder to his service-connected back disability or service, and his own statements on the matter are duplicative to those previously of record at the time of the May 2014 rating decision. the evidence does not contain an opinion relating an ankle disorder to service, nor does it contain an opinion indicating a current ankle disorder is secondary to the service-connected back disability. Therefore, the evidence added to the record since the final May 2014 denial is cumulative or redundant of the evidence of record at the time of the decision and does not raise a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a bilateral ankle disorder. Consequently, new and material evidence has not been received to reopen the claim. 4. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for fibromyalgia. In the May 2014 rating decision, the AOJ considered the Veteran’s service treatment records, post-service treatment records, an April 2014 VA examination, and the Veteran’s lay statements, and denied direct service connection for fibromyalgia on the absence of in-service complaints, treatment, or a diagnosis referable to such disorder and the lack of current diagnosis of such disorder. Since the May 2014 rating decision, additional evidence consisting of VA and private treatment records, VA examination reports, and the Veteran’s lay statements has been received. In this regard, such includes a November 2017 VA examination report reflecting a diagnosis of fibromyalgia. Upon review, the Board finds this diagnosis is new and directly addresses one of the missing elements upon which the previous denial was based. Therefore, the evidence added to the record since the final May 2014 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for fibromyalgia. As such, new and material evidence has been received to reopen the claim of entitlement to service connection for fibromyalgia. Service Connection 5. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected back disability and to include as due to exposure to environmental hazards and/or as an undiagnosed illness, qualifying chronic disability, or medical unexplained chronic multisymptom illness. 6. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to service-connected PTSD and to include as due to exposure to environmental hazards and/or as an undiagnosed illness, qualifying chronic disability, or medical unexplained chronic multisymptom illness. The Veteran asserts that he has fibromyalgia was caused by the pain from his service-connected back disability. He also contends that he has chronic fatigue syndrome secondary to his service-connected PTSD. Alternatively, he contends that such disorders began in service as a result of exposure to black soot from an oil refinery, sulfur factory, jet fumes, and other hazardous materials. In pertinent part, VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A qualifying chronic disability means a chronic disability resulting from an undiagnosed illness or a medical unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, to include chronic fatigue syndrome and fibromyalgia. Id. Notably, signs or symptoms of a medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, joint pain, muscle pain, neurological signs, neuropsychological signs, and sleep disturbances. Additionally, a medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology. Id. Here, the record, to include private treatment records dated in 2017, demonstrates diagnoses of fibromyalgia and chronic fatigue syndrome for which a physician has not provided a conclusive pathophysiology or etiology. In addition, the Veteran’s service personnel records confirm his service in the Southwest Asia theater of operations. Further, the Board finds pertinent the Veteran’s reported symptoms of numbness, generalized body aches, stiffness from resting, sleep problems, memory issues, constipation, and difficulty urinating in addition to fibromyalgia and chronic fatigue syndrome. With consideration of such, the Board finds fibromyalgia and chronic fatigue syndrome manifested to a degree of 10 percent or more not later than December 31, 2021. Therefore, service connection is warranted for fibromyalgia and chronic fatigue service as medically unexplained chronic multisymptom illnesses. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). 7. Entitlement to an initial rating in excess of 10 percent for limitation of adduction of the right hip. 8. Propriety of the separate rating for limitation of extension of the right hip, evaluated as noncompensably disabling as of January 31, 2018. 9. Propriety of the separate rating for limitation of flexion of the right hip, evaluated as noncompensably disabling as of January 31, 2018. The Veteran asserts that his right hip disability is more severe than as reflected by the currently assigned ratings during the appeal period. Initially, the Board notes the most recent April 2018 Rating Code Sheet erroneously identifies the Diagnostic Codes pertinent to the assigned ratings, which the Board has corrected herein. Throughout the appeal period, a 10 percent rating is assigned for the Veteran’s right hip disability based on limitation of adduction under Diagnostic Code 5253. As of January 31, 2018, separate noncompensable ratings are assigned for limitation of extension and limitation of flexion under Diagnostic Codes 5251 and 5252, respectively. Here, the Board will review the entirety of the evidence with consideration of higher and/or additional separate ratings for the Veteran’s service-connected right hip disability. Under Diagnostic Code 5251, addresses limitation of extension of the thigh, and provides a maximum 10 percent rating where extension is limited to five degrees. Under Diagnostic Code 5252 addresses limitation of flexion of the thigh, and provides a 10 percent rating is assigned for flexion limited to 45 degrees, and a 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is provided for flexion limited to 20 degrees, and a 40 percent rating is provided for flexion limited to 10 degrees. Diagnostic Code 5253 addresses impairment of the thigh, and provides a 10 percent rating for limitation of rotation when one cannot toe-out more than 15 degrees, or limitation of adduction when one cannot cross legs. A 20 percent rating is assigned for limitation of abduction with motion lost beyond 10 degrees. 38 C.F.R. 4.71a. In order to assign a rating in excess of 10 percent based on impairment of the thigh, the evidence must demonstrate limitation of abduction with motion lost beyond ten degrees, or the functional impairment comparable thereto. Here, medical examinations and treatment records dated in February 2008, January 2010, February 2016, and January 2018 reflects limitation of abduction to 45 degrees, 45 degrees, 35 degrees, and 25 degrees, respectively, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups. Therefore, an initial rating in excess of 10 percent under Diagnostic Code 5253 is not warranted. The Veteran also asserts that his right hip disability deserves compensable ratings based on additional limited range of motion, specifically to include extension and flexion. As noted above, compensable ratings for limitation of extension and flexion are provided for extension limited to five degrees and flexion limited to 45 degrees. Medical records show that, throughout the appeal period, extension was limited to, at most, 10 degrees while flexion was limited to, at most, 60 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion or flare-ups. As a result, the Board finds compensable ratings are not warranted under Diagnostic Codes 5251 and 5252 based on extension limited to five degrees or flexion limited to 45 degrees. Despite the fact that the Veteran does not meet the criteria for a compensable rating for limitation of extension or flexion, and his functional impairment resulting from pain and limited motion is already contemplated in his currently assigned 10 percent rating based on limitation of adduction, the AOJ granted separate, noncompensable ratings for limitation of extension and flexion, effective January 31, 2018, the date of the most recent VA examination. In an April 2018 rating decision, the AOJ found the January 31, 2018, VA examination report is the first to demonstrate significant, limited functional ability with flare-ups and additional limitation of range of motion due to pain. Upon review, the Board finds the assigned, noncompensable ratings for the right hip disability based on limitation of extension and flexion are proper, as well as the effective dates for the award of such. Prior to January 31, 2018, the medical evidence does not reflect additional limitation due to pain or functional loss due to extension or flexion. The February 2008 examination report shows range of motion was within normal limits; a January 2010 report shows no additional loss of motion upon repetition; and an April 2011 indicates the Veteran had no symptoms associated with his right hip disability. Further, the February 2016 VA examination report demonstrates a finding of no additional loss of motion, due to pain, of function or range of motion after three repetitions. The examiner noted it was possible that there may be additional limitations in function or range of motion with flare-ups, but an examiner would need to be present at the time to assess such losses. Here, the Board finds this speculation does not rise to the standard necessary to award additional compensable ratings beyond that of the 10 percent assigned for limitation of adduction. The Board finds the February 2016 and January 2018 VA examinations, which considered the Veteran’s lay statements and completed all testing indicated by DeLuca, supra, and Mitchell, supra, particularly probative. See Nieves-Rodriguez, supra; Dalton, supra. In this regard, the Board notes the Veteran endorsed flare-ups at both examinations, but while the February 2016 examiner considered the possibility of additional loss of limitation of motion with flare-ups, he did not find the Veteran had additional loss of function due to pain or range of motion after three repetitions. Conversely, the January 2018 examiner found additional limitation of range of motion due to pain. Based on the foregoing, the Board finds compensable ratings for the Veteran’s right hip disability rated based on limitation of extension and/or flexion are not warranted. Diagnostic Code 5251 provides a 10 percent rating for extension limited to 5 degrees; however, at no point pertinent to the appeal period did the Veteran exhibit such limitation, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Furthermore, while the Veteran exhibited limitation of flexion, such did not rise to the level necessary for a compensable rating under Diagnostic Code 5252. Specifically, at no point during the appeal period was the Veteran’s flexion limited to 45 degrees or greater, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Additionally, the Board has considered whether additional separate ratings may be assigned for the Veteran’s service-connected right hip disability. However, the medical evidence does not reflect ankylosis, flail joint, or impairment of the femur at any time during the appeal period. 38 C.F.R. 4.71a, Diagnostic Codes 5250, 5254, 5255. Furthermore, the Board finds that, to assign separate ratings for painful motion in each range would constitute impermissible pyramiding as the relevant regulation applies to the joint as a whole, not each applicable limitation of motion. See 38 C.F.R. §§ 4.14, 4.59; Esteban, supra. Therefore, an initial rating in excess of 10 percent for the Veteran’s right hip disability due to impairment of thigh is not warranted, and the separate noncompensable ratings assigned as of January 31, 2018, for limitation of extension and flexion were proper. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the instant claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected right hip disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Therefore, the Board finds that higher or separate ratings for the Veteran’s right hip disability is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, such doctrine is not applicable in the instant appeal and his initial rating claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 10. Entitlement to a compensable rating for left ear hearing loss. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. If impaired hearing is service-connected in only one ear, as is the case here, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I. 38 C.F.R. § 4.85(f). The Veteran’s service-connected left ear hearing loss is currently assigned a noncompensable rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. In March 2017, he filed a claim for an increased rating for such disability. On VA examination in May 2017, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 LEFT 25 25 30 35 The Veteran’s speech recognition ability was 96 percent in his left ear. On the basis of the numbers shown above, his pure tone threshold average for the left ear was 28.75 decibels. No exceptional pattern of hearing loss was shown. Applying 38 C.F.R. § 4.85, Table VI to the April 2011 audiological findings, the Veteran’s right ear hearing loss is a Level I impairment and his left ear hearing loss is a Level I impairment. Applying the criteria from Table VI to Table VII, a noncompensable rating is derived. On private examination in June 2017, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 LEFT 30 25 25 25 The Veteran’s speech recognition ability was 100 percent in his left ear. Based on the numbers shown above, the Veteran’s pure tone threshold average for the left ear was 26.25 decibels. No exceptional pattern of hearing loss was shown. Applying 38 C.F.R. § 4.85, Table VI to the June 2017 audiological findings, the Veteran’s left ear hearing loss is a Level I impairment. Applying the criteria from Table VI to Table VII, a noncompensable rating is derived. The Board recognizes and has considered the Veteran’s assertions regarding the impact of his left ear hearing loss on his daily life. Throughout the appeal, he reported difficulty with conversation and understanding speech and frequently having to ask people to repeat themselves. In this regard, while the Veteran is competent to report the effects of his hearing loss on his daily functioning, he is not competent to report that his hearing acuity is of sufficient severity to warrant a 10 percent or greater evaluation under VA’s tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Despite the foregoing, the Board acknowledges the Veteran’s aforementioned reports of the difficulties associated with his left ear hearing loss. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a compensable evaluation are not met. See Lendenmann, supra (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). Additionally, the Veteran and his representative have requested extraschedular consideration for a compensable rating for his left ear hearing loss. In Doucette, supra, the Court held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment as these are the effects that VA’s audiometric tests are designed to measure. The Veteran has not otherwise described functional effects that are considered exceptional or, that are not otherwise contemplated by the assigned evaluation. Thus, his complete disability picture is compensated under the rating schedule. Further, neither he nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the instant claim. Id. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected left ear hearing loss; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Therefore, the Board finds a compensable rating for left ear hearing loss is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, such doctrine is not applicable in the instant appeal and his increased rating claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 11. Entitlement to service connection for a left elbow disorder. The Board herein has reopened the claim of entitlement to service connection for a left elbow disorder and finds remand is necessary to obtain an addendum opinion addressing the etiology of such disorder. In this regard, in March 2018, a VA examiner diagnosed triceps tendinitis, and provided a negative nexus opinion based on the absence of continuity of elbow care until October 2007 and none thereafter. Here, it does not appear the VA examiner considered or addressed the Veteran’s reports of symptoms since the initial in-service symptoms. Generally, “symptoms, not treatment, are the essence of any evidence of continuity of symptomatology.” Savage v. Gober, 10 Vet. App. 488, 496 (1997), citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991); see also 38 C.F.R. § 3.303 (2017). Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, remand is warranted for an addendum opinion to determine whether any left elbow disorder is related to military service, with particular consideration of the Veteran’s lay statements concerning his symptoms. 12. Entitlement to service connection for sleep apnea, to include as secondary to service-connected back disability. In December 2012, the AOJ granted service connection for PTSD with depression and sleep problems, finding the decision constituted a complete grant of the claim of entitlement to service connection for a sleep disorder. On appeal, the Veteran asserts he has sleep apnea that is separate and distinct from the symptoms associated with his service-connected PTSD and directly related to service. Alternatively, he contends such is related to his service-connected back disability. The medical evidence reflects a diagnosis of obstructive sleep apnea during the pendency of the appeal. Also in support of his claim, the Veteran submitted a March 2018 letter from a private physician, Dr. A.M. Dr. A.M. found the Veteran had psychophysiologic insomnia that was “partially contributed by chronic back pain”. The physician further found the Veteran’s deployment could have been the precipitating factor. Conversely, on VA examination in March 2018, a VA examiner opined the Veteran’s obstructive sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner based the opinion on the absence of documentation until March 2010, at which time, a sleep study was negative. In addition, a June 2017 sleep study showed mild sleep apnea with no prior documentation of such issue. Upon review, the Board finds the private physician’s opinions speculative and without probative value. Likewise, it does not appear the VA examiner considered the Veteran’s lay statements regarding his in-service and post-service symptoms. Furthermore, neither opinion thoroughly addressed, with sufficient rationale, the issue of a relationship between any current sleep disorder and the Veteran’s service-connected back disability. As a result, the Board finds remand is necessary for an addendum opinion addressing the etiology of the Veteran’s sleep apnea. Additionally, the Veteran submitted a VA Form 21-4142, General Release for Medical Provider Information in September 2018, reporting additional private treatment for his sleep apnea from Genesis Sleep Center dated from April 2017 to October 2018. As VA has not attempted to obtain such records, remand is also warranted to do so. 13. Entitlement to service connection for hypertension as secondary to service-connected disability. The Veteran asserts he has hypertension secondary to his service-connected PTSD, residuals of CVA, and/or back disability. An August 2017 VA examiner found the Veteran did not have a diagnosis of hypertension. An April 2018 VA examiner diagnosed hypertension, but opined that such was less likely than not proximately due to or the result of, or aggravated by, his service-connected disabilities of PTSD, CVA, and back disability. However, he reported the Veteran’s hypertension was “due to micro-adenoma of anterior pituitary (diagnosed April 2017)” and stated hypertension was “at least as likely as not aggravated beyond its natural progression by the service connection condition.” In light of the contradictory opinions, the Board finds remand is warranted to obtain an addendum opinion. 14. Entitlement to a rating in excess of 10 percent for residuals of CVA. The Veteran asserts the residuals of his service-connected CVA are more severe than currently contemplated by the rating assigned. He last underwent VA examination in August 2017 for such disability. The VA examiner reported the examination was normal from a neurological standpoint. In a September 2017 written statement, the Veteran indicates, and the VA examination report confirms, that he did not undergo any diagnostic testing in August 2017, and he believes he should have undergone a CAT scan. In light of the Veteran’s request, the Board remands the issue to determine whether any additional testing is necessary to properly rate the severity of any residuals of CVA. 15. Entitlement to an initial rating in excess of 10 percent prior to September 28, 2017, and in excess of 40 percent thereafter for back disability. 16. Propriety of the separate rating assigned for radiculopathy of the right lower extremity, evaluated as 10 percent disabling as of February 24, 2016. 17. Propriety of the separate rating assigned for surgical scar of the lower back, evaluated as noncompensably disabling as of April 6, 2016. The Veteran contends the currently assigned ratings for his back disability do not properly reflect the severity of such disability. He last underwent VA examination in January 2018 in regard to such disability. However, the record includes a September 2018 statement in support of claim reflecting the Veteran’s report of more than six weeks of prostrating episodes that caused him to take off work. As such suggests that the Veteran’s symptoms may have increased in severity since the last VA examination, a remand is necessary to obtain afford him an appropriate VA examination to assess the current nature and severity of his back disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Further, as such examination will address the severity of the Veteran’s radiculopathy of the right lower extremity and surgical scar of the lower back, such claims must likewise be remanded. 18. Entitlement to a rating in excess of 50 percent for PTSD. 19. Entitlement to an effective date prior to March 6, 2017, for the award of a 50 percent rating for PTSD. The Veteran contends the currently assigned 50 percent rating for his PTSD does not properly reflect the severity of his symptoms. He last underwent VA examination in March 2017 to ascertain the nature and severity of such disability. However, since such examinations, the Board finds VA treatment records indicate his PTSD symptoms, specifically to include impulse control, avoidance, anxiety, and lack of hygiene, may have increased in severity. Additionally, VA treatment records indicate the Veteran was hospitalized for suicidal ideation in March 2017; however, the evidence does not appear to include those records, and as such, the March 2017 VA examiner was unable to review such records, as clearly indicated by the report reflecting no history of psychiatric hospitalizations. Consequently, remand is necessary to obtain records pertaining to such hospitalization and to afford him a contemporaneous VA examination to assess the current nature and severity of his PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The Veteran also asserts that the correct effective date for the award of a 50 percent rating for PTSD is June 1, 2008, the date of receipt of his initial claim. As the development requested herein with respect to the increased rating claim for PTSD could provide additional information regarding the effective date at issue, such claims are inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). Therefore, consideration of the assignment of an earlier effective date must be deferred pending the completion of the foregoing development. 20. Entitlement to an initial compensable rating for eczema. In the August 2017 Joint Motion for Partial Remand, the Court found the Board erred in its reliance on a February 2016 medical opinion that did not comply with the December 2015 Board remand. Specifically, the Board directed that the examiner should address the Veteran’s complaints of flare-ups and, if he did not have a flare-up during the examination, the examiner should “attempt to estimate the effects of the flared-up condition based on the lay statements of the Veteran regarding the severity of his condition during a flare-up. In this regard, the Board noted the Veteran’s report that his eczema affected 5 to 20 percent of his exposed body area during a flare-up. The February 2016 VA examiner acknowledged the Veteran’s statements, but found that his competence to report symptoms is not synonymous with credibility. Consequently, he did not provide the requested opinion. Therefore, a remand is necessary in order to afford the Veteran a new VA examination that addresses the nature and severity of his eczema. The matters are REMANDED for the following action: 1. After obtaining any necessary authorization from the Veteran, obtain the private treatment records from Genesis Sleep Center dated from April 2017 to October 2018 as identified in the September 2018 VA Form 21-4142, and those records pertaining to his March 2017 hospitalization for PTSD. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Return the record to the examiner who conducted the March 2018 VA elbow and forearm conditions examination. The record must be made available to the examiner. If the March 2018 VA examiner is not available, the record should be provided to an appropriate medical professional to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Identify all current left elbow disorders. (B) For each currently diagnosed disorder, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to the Veteran’s military service, to include his October 2007 and January 2008 complaints of crepitus, popping, and pain. In offering any opinion, the examiner should consider the Veteran’s statements regarding the onset and continuity of his symptomatology. A rationale should be offered for any opinion provided. 3. Return the record to the examiner who conducted the March 2018 VA sleep apnea examination. The record must be made available to the examiner. If the March 2018 VA examiner is not available, the record should be provided to an appropriate medical professional to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea is related to his military service, to include his report of an inability to sleep in October 2007, which, at the time, was attributed to insomnia. (B) Offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s sleep apnea is caused or aggravated by his back disability. For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In offering any opinion, the examiner should consider the Veteran’s statements regarding the onset and continuity of his symptomatology, and Dr. A.M.’s March 2018 opinion relating his sleep apnea, in part, to his back disability. A rationale should be offered for any opinion provided. 4. Return the record to the examiner who conducted the April 2018 VA hypertension examination. The record must be made available to the examiner. If the April 2018 VA examiner is not available, the record should be provided to an appropriate medical professional to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is caused or aggravated by his service-connected PTSD, residuals of CVA, and/or back disability. For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 5. Afford the Veteran an appropriate VA examination to determine the current nature and severity of any residuals of CVA. The record, to include a complete copy of this Remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and lay assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should describe the nature and severity of all manifestations from the CVA. In this regard, the examiner should specifically indicate whether any additional testing is necessary to properly identify the nature and severity of any residuals of CVA. The examiner should also describe the functional impairment resulting from such disability. A rationale should be provided for any opinion offered. 6. Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected back disability and associated radiculopathy of the right lower extremity and surgical scar of the lower back. The record, to include a complete copy of this Remand, must be made available to the examiner and all indicated tests should be accomplished. If possible, the examination should be conducted during a flare-up of the Veteran’s back disability. (A) The examiner should identify the current nature and severity of all manifestations of the Veteran’s back disability. (B) The examiner should record the range of motion of the lumbar spine observed on clinical evaluation in terms of degrees for all planes. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination, results in any loss of range of motion. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case he or she should clearly explain why that is so. (C) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use. In this regard, the examiner should indicate whether, and to what extent, the Veteran’s range of motion is additionally limited during flare-ups or on repetitive use, expressed, if possible, in terms of degrees, or explain why such details cannot be feasibly provided. (D) If the Veteran endorses experiencing flare-ups of his back disability, the examiner must obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. (E) Then, if the examination is not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of range of motion that may be present during a flare-up. If the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. (F) The examiner is requested to indicate whether intervertebral disc syndrome related to the Veteran’s service-connected back disability is present. If so, the examiner should the total duration of any incapacitating episodes over the past 12 months. The examiner is advised that an ‘incapacitating episode’ is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. (G) The examiner is also requested to indicate whether the Veteran’s back disability results in any objective neurologic impairment other than radiculopathy of the right lower extremity, to include radiculopathy of the left lower extremity, and/or bladder or bowel impairment, and, if so, the nature and severity of such neurologic impairment. The examiner should also address the nature and severity of the Veteran’s radiculopathy of the right lower extremity. (H) The examiner should also address the nature and severity of the Veteran’s surgical scar of the lower back. (I) The examiner should also comment upon the functional impairment resulting from the Veteran’s back disability and associated radiculopathy of the right lower extremity and surgical scar of the lower back. A rationale for all opinions offered should be provided. 7. Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected PTSD. The record, to include a complete copy of this Remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should describe the nature and severity of all manifestations of the Veteran’s PTSD, and the resulting functional impairment of such disability on the Veteran’s social and occupational functioning. A rationale should be provided for any opinion offered. 8. Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected eczema. The record, to include a complete copy of this Remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. If possible, the examination should be conducted during a flare-up of the Veteran’s eczema. (A) The examiner should describe the nature and severity of all manifestations of the Veteran’s eczema. He or she should note the percentage of the entire body and exposed areas affected by such disability and identify the prescribed treatment(s). The examiner should specifically indicate whether such treatment constitutes systemic therapy, i.e., affecting the body as a whole, or is like or similar to corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs, and, if so, whether such treatment was required. (B) If the examiner determines that the Veteran experiences flare-ups or additional symptoms of his eczema, but they are not observable at the current time, he or she should estimate the entire body and exposed areas affected when it is in an active phase. In this regard, the examiner should consider the Veteran’s report that his eczema affected 5 to 20 percent of his exposed body area during a flare-up. (C) The examiner should describe the functional impairment associated with the Veteran’s eczema. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.M. Celli, Counsel