Citation Nr: 18159939 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 11-14 947 DATE: December 20, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for bipolar disorder, claimed as cyclothymia is reopened. Entitlement to a compensable rating for chronic bronchitis, prior to May 7, 2009 is denied. Entitlement to a rating of 10 percent, but no higher, for chronic bronchitis is warranted from May 7, 2009. Entitlement to an effective date earlier than July 7, 1998 for service connection of bronchitis is dismissed. Entitlement to service connection for a personality disorder, mixed with features of histrionic narcissistic antisocial personality disorder is dismissed. REMANDED Entitlement to service connection for obsessive compulsive disorder is remanded. Entitlement to service connection for generalized anxiety disorder is remanded. Entitlement to service connection for bipolar disorder, claimed as cyclothymia is remanded. FINDINGS OF FACT 1. In a July 1998 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for bipolar disorder, claimed as cyclothymia. The Veteran did not file a notice of disagreement with the decision or submit new and material evidence within one year of the denial. 2. Evidence received since the final July 1998 rating decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for bipolar disorder. 3. Throughout the period on appeal, the Veteran’s chronic bronchitis has been marked by FEV-1 readings greater than 80 percent predicted, FEV-1/FVC readings greater than 80 percent predicted, and DLCO (SB) readings greater than 80 percent predicted. There has been no evidence of cor pulmonale, right ventricular hypertrophy, or pulmonary hypertension, and the Veteran has not required outpatient oxygen therapy. 4. Prior to May 7, 2009, there is no evidence that the Veteran used inhalational or oral bronchodilator therapy to treat chronic bronchitis. 5. Resolving all reasonable doubt in the Veteran’s favor, from May 7, 2009, he has intermittently used inhalational bronchodilator therapy to treat chronic bronchitis; throughout the period on appeal, there is no evidence that the condition has required the use of corticosteroids, immuno-suppressive medications, or at least monthly visits to a physician for required care of exacerbations. 6. In a July 2018 written communication, the Veteran, through his representative, requested to withdraw the issue of entitlement to service connection for a personality disorder, mixed with features of histrionic narcissistic antisocial personality disorder. 7. In the absence of a timely appeal of the July 1998 rating decision with respect to the assigned effective date of service connection for chronic bronchitis, that decision is final; an effective date prior to July 7, 1998 is not assignable. CONCLUSIONS OF LAW 1. The August 2012 rating decision that denied claim of entitlement to service connection for bipolar disorder, claimed as cyclothymia, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.1103 (2018). 2. The criteria for reopening a previously denied claim of entitlement to service connection for bipolar disorder have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. Prior to May 7, 2009, the criteria for entitlement to a compensable rating for chronic bronchitis were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.97, Diagnostic Codes 6600, 6602 (2018). 4. From May 7, 2009, the criteria for entitlement to a rating of 10 percent, but no higher, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.97, Diagnostic Codes 6600, 6602 (2018). 5. An effective date prior to July 7, 1998, for the grant service connection for chronic bronchitis is dismissed. 38 U.S.C. §§ 5110, 7105 (2012); 38 C.F.R. §§ 3.400, 20.302, 20.1103 (2018); Rudd v. Nicholson, 20 Vet. App. 296 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1990 to May 1990; from October 1990 to May 1991; from August 1991 to March 1992; and from January 1993 to February 1994, to include service in Southwest Asia from November 1990 to April 1991. The Veteran also served in the Army National Guard. This case comes on appeal of July 1998 and January 2016 rating decisions. Regarding the claims for chronic bronchitis, the Board has remanded the case on multiple occasions to instruct the AOJ to provide further development. Dismissed Appeals By way of background, VA granted entitlement to service connection for chronic bronchitis at a noncompensable level in a July 1998 rating decision, effective July 7, 1998. In August 1998, the Veteran submitted a timely notice of disagreement, expressing that he did not agree with the assigned rating. The appeal has continued from that rating decision to the present. In March 2010, the AOJ issued a rating decision granting an increased rating of 10 percent for chronic bronchitis, effective September 22, 2009. The Veteran disagreed in April 2010. In November 2010, the Veteran’s representative submitted a second notice of disagreement with the March 2010 decision. At that time, the Veteran’s representative asserted that VA had never finally adjudicated the Veteran’s initial claim, that the rating of 10 percent should have been awarded effective earlier than September 22, 2009, and that the entire claim dated back to October 6, 1997—the date that the Veteran filed a claim of entitlement to service connection for cyclothymia. Regarding whether the 10 percent rating (or higher) for chronic bronchitis can be awarded anytime during the appeal period prior to September 22, 2009, that issue remained on appeal, irrespective of the representative’s notice of disagreement. In a claim for an increased rating, the Board reviews the appropriateness of the rating for the entire period on appeal. Since the AOJ’s March 2010 decision was not, in fact, a full grant of benefits sought (even though it stipulated as much), the propriety of the rating for the entire appeal period [July 7, 1998 to today] is before the Board, and will be discussed below. However, insofar as the Veteran’s representative argued in November 2010 that the increased rating should be made effective October 6, 1997—a time pre-dating the effective date for the award of service connection—the Board will not accept jurisdiction over that matter, as it amounts to a challenge to the effective date for the award of service connection well after the time for appealing that determination has run. Indeed, if service connection is established for a particular disability, and the veteran is assigned an effective date for the award, he has the right to appeal the effective date. See, e.g., 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302. If he does not initiate an appeal of the effective date within one year, however, the RO’s decision with respect to the effective date becomes final, and no subsequent “free-standing” claim for an earlier effective date may be entertained. See 38 C.F.R. §§ 20.302 (a), 20.1103; Rudd v. Nicholson, 20 Vet. App. 296 (2006). Here, the effective date of July 7, 1998 was established in the July 1998 rating decision. Although the Veteran filed a notice of disagreement with the initial rating in that decision, he did not file a notice of disagreement with the effective date within one year, thus the effective date became final. The November 2010 notice of disagreement from the Veteran’s representative, insofar as it requests an initial rating that pre-dates the date service connection became effective, therefore constitutes a free-standing claim for an earlier effective date for the award of service connection. Accordingly, such a claim lacks legal merit and is dismissed. Although the AOJ, in an August 2017 supplemental statement of the case evaluated and denied the claim for an earlier effective date of service connection, this appears to have been in error. The Board notes that if the Veteran wishes to challenge the effective date of service connection for chronic bronchitis, he should file a claim for CUE with a prior rating decision. As noted above, the Board will accordingly review the evaluation of the Veteran’s chronic bronchitis solely as it would for any initial rating claim, evaluating the propriety of the rating for the entire period on appeal. Additionally, under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege a specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204(c). In July 2018 written correspondence, the Veteran, through his representative, requested to withdraw from consideration the issue of entitlement to service connection for a personality disorder, mixed with features of histrionic narcissistic antisocial personality disorder. As the Veteran has withdrawn his appeal regarding this issue, there remain no allegations of error of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal on this issue, and it is dismissed. Request to Reopen a Previously Denied Claim 1. Whether new and material evidence was received to reopen a claim of entitlement to service connection for bipolar disorder, claimed as cyclothymia If a claim of entitlement to service connection has previously been denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. 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). The evidence VA is required to review for newness and materiality is that which has been submitted by the claimant since the last final disallowance of the claim on any basis. See Evans v. Brown, 9 Vet. App. 273 (1996). For the purpose of determining whether a case should be reopened, the credibility of the evidence added to the record is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Shade, 24 Vet. App. at 118. The Veteran first filed a claim of entitlement to service connection for cyclothymia in October 1997. The RO denied the claim in a July 1998 rating decision and the Veteran did not submit a notice of disagreement or new and material evidence within one year of the decision; therefore, the decision became final. This represents the most recent final denial. The Board must consider whether the Veteran has provided new and material evidence since that decision. At the time of the July 1998 rating decision, the Veteran’s actual diagnosed disability was unclear. An April 1994 private examination had stated that it was conceivable that there was an element of bipolar disorder, and perhaps cyclothymia, or, alternatively, neurotic disorders, personality disorders, or attention deficit disorders, but ultimately described the Veteran’s condition as depressive disorder. A January 1998 VA examination diagnosed cyclothymic bipolar disorder, while a May 1998 VA examination referred to the Veteran’s condition as manic-depressive. Since the final July 1998 rating decision, the Veteran has submitted significant medical evidence describing his mental health condition. This evidence confirmed a diagnosis of bipolar disorder, which was not concrete at the time of the rating decision. This evidence, therefore, is both new and material to the claim. Without yet addressing the probative value of this additional evidence, the Board acknowledges that the evidence satisfies the low threshold of new and material evidence required to reopen the claim. To this extent only, the appeal is granted. Increased Rating 2. Entitlement to a compensable rating for chronic bronchitis, prior to September 22, 2009, and in excess of 10 percent from September 22, 2009 Disability evaluations are determined by the application of the facts presented to the VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disabilities. 38 C.F.R. § 4.14. Generally, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has also held that within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise. Cullen v. Shinseki, 24 Vet. App. 74 (2010). In a July 1998 rating decision, the AOJ granted service connection for bronchitis at a noncompensable rating under Diagnostic Code 6600, effective July 7, 1998. 38 C.F.R. § 4.97. The Veteran timely disagreed with the initial rating, and the issue has remained on appeal. In a March 2010 rating decision, the AOJ determined that the Veteran qualified for a higher rating under Diagnostic Code 6602, rating the condition as analogous to bronchial asthma. 38 C.F.R. § 4.97. The Board notes that there are similar, but distinct, criteria for each of these diagnostic codes and will analyze the Veteran’s disability under each. Diagnostic Code 6600 Under Diagnostic Code 6600, chronic bronchitis is assigned a rating based on Forced Expiratory Volume in one second (FEV-1), Forced Vital Capacity (FVC), and diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO (SB)) measurements. A 10 percent rating is assigned with the FEV-1 is 71 to 80 percent of predicted value, or; FEV-1/FVC is 71 to 80 percent of predicted value, or; DLCO (SB) is 66 to 80 percent of predicted value. A 30 percent rating is assigned when the FEV-1 is 56 to 70 percent predicted, or; FEV-1/FVC is 56 to 70 percent predicted, or; DLCO (SB) of 56 to 65 percent predicted. A 60 percent rating is assigned when the FEV-1 is 40 to 55 percent predicted, or; FEV-1/FVC is 40 to 55 percent predicted, or; DLCO (SB) of 40 to 55 percent predicted, or with maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A maximum 100 percent rating is awarded for FEV-1 less than 40 percent of predicted value; or the ratio of FEV-1/FVC is less than 40 percent; or DLCO (SB) less than 40 percent predicted; or maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo or cardiac catheterization); or episode(s) of acute respiratory failure; or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6600. VA amended the rating schedule for rating respiratory disabilities, effective October 6, 2006. VA added provisions that clarify the use of pulmonary function tests (PFTs) in rating respiratory conditions. A new 38 C.F.R. § 4.96(d), titled “Special provisions for the application of evaluation criteria for diagnostic codes 6600, 6603, 6604, 6825-6833, and 6840-6845” has seven provisions. PFTs are required to rate respiratory conditions except in certain situations. If a DLCO (SB) test is not of record, rating should be based on alternative criteria as long as the examiner states why the DLCO (SB) test would not be useful or valid in a particular case. When the PFTs are not consistent with clinical findings, rating should generally be based on the PFTs. Post-bronchodilator studies are required when PFTs are done for rating purposes with some exceptions. When rating based on PFTs, post-bronchodilator results are to be used unless they are poorer than the pre-bronchodilator results, then the pre-bronchodilator values should be used for rating purposes. When the results of different PFTs (FEV-1, FVC, etc.) are disparate, the test result that the examiner states most accurately indicates the level of disability should be used for rating, and if the FEV-1 and the FVC are both greater than 100 percent, a compensable rating based on a decreased FEV-1/FVC ratio should not be assigned. 38 C.F.R. § 4.96(d). A December 1997 note from the Marion VA Medical Center shows that the Veteran had a chest x-ray that identified chronic lung changes. The report noted no active focal lung changes were present, but that chronic granulomatous changes with increased lung markings were shown. In April 1998, a follow-up chest x-ray confirmed old granulomatous disease with no active infiltrate. In a July 1998 rating decision, the AOJ granted service connection for chronic bronchitis at a rating of 0 percent. The rating decision stated that, although the Veteran did not have documented recurrence of bronchitis since 1993, because he had been diagnosed with bronchitis in service, had complained of shortness of breath at times post-service, and had x-ray evidence of chronic granulomatous changes, the AOJ resolved reasonable doubt in the Veteran’s favor to grant service connection. No PFT had been given at that time, as there was no evidence of continued chronic bronchitis. In April 1999, the Veteran underwent a VA respiratory examination. The examiner reported that the Veteran did not have any cough at the present time, but that the Veteran periodically had shortness of breath and bronchitis. Shortness of breath was mostly on exertion and bronchitis occurred about four times per year for which he would often have an antibiotic. The examiner reported no asthma and no treatment for a respiratory condition. On physical examination, there was no evidence of cor pulmonae, right ventricular hypertrophy, or pulmonary hypertension. The examiner diagnosed chronic bronchitis with periodical exacerbations, chronic granulomatosis changes in the lungs, and early obstructive pulmonary impairment. Later in April 1999, the Veteran underwent a PFT with the VA Northern Indiana Health Care System. At that time, FEV-1 results were 87 percent for predicted, pre-bronchodilator, and 91 percent of predicted, post-bronchodilator. FEV-1/FVC ratio was 100 percent of predicted, pre-bronchodilator, and 108 percent of predicted, post-bronchodilator. DLCO measurements were 88 percent of predicted. The examiner reported that possible early obstructive pulmonary impairment was suggested by a reduced forced expiratory flow at 25 percent to 75 percent (FEF 25-75), given a normal FVC and FEV-1. However, based on the spirometry results at that time, the Veteran’s condition did not warrant a compensable rating. An April 2001 chest x-ray continued to identify calcified nodes and granulomata consistent with old granulomatous disease, but found no infiltrate or pleural effusion. The impression was no active pulmonary disease. The Veteran underwent a new VA respiratory examination in December 2005. The examiner noted the Veteran’s reported history of tightness in the chest, as well as wheezing and shortness of breath on exertion. The Veteran reported a dry cough from time to time and occasional specks of blood during flares of bronchitis. The Veteran did not use oxygen or any medications or inhalers for these symptoms. On physical examination, the Veteran’s chest was unlabored and clear to auscultation bilaterally with no expiratory wheezes. There was no evidence of any pulmonary hypertension. The examiner reported that he did not have access to any pulmonary function tests for review, but suggested that should the Veteran have ongoing pulmonary symptoms, they be formally evaluated in the Pulmonology Clinic with formal PFT testing. In a January 2006 addendum opinion, the examiner noted that he did not have the Veteran’s claims file at the time of the prior examination. Having since looked over the file, the examiner noted that the Veteran’s April 1999 spirometry results were within normal limits and revealed no evidence of any obstructive or restrictive defects. The Veteran underwent a new PFT with a private physician in January 2007, however the examiner only recorded pre-bronchodilator findings. At that time, FEV-1 results were 88 predicted. FEV-1/FVC ratio was 108 percent. DLCO measurements were not recorded. Even without post-bronchodilator results, these measurements did not warrant a compensable rating. The Veteran underwent a new pulmonary function test in May 2009. At that time, FEV-1 results were 83 percent of predicted, pre-bronchodilator, and 88 percent of predicted, post-bronchodilator. FEV-1/FVC ratio was not reported as compared to predicted amounts, however the predicted amount was 81; the pre-bronchodilator amount was 79 while post-bronchodilator amount was 82. DLCO measurements were 88 percent of predicted. In the diagnostic study report, the examiner reported normal spirometry with no significant bronchodilator response, and normal DLCO. The study accompanied a full examination. The examination report recorded a history of a non-productive cough and dyspnea on severe exertion. The pulmonary examination was normal and the lungs were grossly clear. There was no acute cardiopulmonary abnormality. These results do not warrant a compensable rating. There are no additional PFTs or respiratory examinations since May 2009. In May 2011, the Veteran’s representative at the time submitted an addendum argument in which he claimed that by comparing the Veteran’s results from his January 2007 PFT with the expected results of the May 2009 PFT, the results would be of a percentage that would warrant a higher rating. The representative argued that there was no reason for the expected results to increase from January 2007 to May 2009, therefore the compared results should be accepted. The Board notes that interpreting and reporting on the results of PFTs requires specialized medical knowledge. The Veteran’s representative, as a layperson, was not competent to make such assertions, and the argument is not considered probative evidence. See, Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the preponderance of the probative evidence is against a finding that the Veteran’s condition warranted a compensable rating at any point during the claim period under Diagnostic Code 6600. Diagnostic Code 6602 Diagnostic Code 6602 provides for a 10 percent evaluation for bronchial asthma when PFT shows FEV-1 is 71-80 percent of the predicted amount, or; FEV-1/FVC is 71-80 percent of the predicted amount, or; intermittent inhalational or oral bronchodilator therapy is used. A 30 percent rating is warranted where FEV-1 is 56 to 70 percent predicted; FEV-1/FVC is 56 to 70 percent predicted; or there is daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. A 60 percent rating is warranted where FEV-1 is 40 to 55 percent predicted; FEV-1/FVC of 40 to 55 percent; or there are at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent disability rating is warranted where FEV-1 is less than 40 percent predicted; FEV-1/FVC is less than 40 percent predicted; or more than one attack per week with episodes of respiratory failure, or where the use of systemic high dose corticosteroids or immunosuppressive medications are required on a daily basis. 38 C.F.R. § 4.97, Diagnostic Code 6602. The provisions of 38 C.F.R. § 4.96 do not apply to Diagnostic Code 6602. The results of the Veteran’s PFTs have been discussed at length above. Notably, the same PFT results that would warrant a compensable rating under Diagnostic Code 6600 are also required to warrant a compensable rating under Diagnostic Code 6602. The Veteran was granted a 10 percent rating under Diagnostic Code 6602 after being given a bronchodilator inhaler by a private physician in a September 2009 appointment. The Board notes that the Veteran’s representative, in a July 2018 correspondence, argued that the Veteran should be given a rating of 10 percent back to the original date of the claim, based on statements in the report of the April 1999 PFT discussed above. In that report, the examiner stated that the FEF 25-75 was significantly increased, indicating that the Veteran “would most likely benefit from continued bronchodilator therapy.” The Veteran’s representative argues that “There is no practical difference between the Veteran’s doctor prescribing bronchodilatory therapy in 2009 and the VA doctor opining that the Veteran would benefit from bronchodilator therapy in 1999.” The Board disagrees. The rating criteria requires use of inhalational or bronchodilator therapy. Whether the Veteran did so is a question of fact. The Veteran did not use them prior to 2009, nor does he allege that he used them. The Veteran also does not allege that that any of his treating physicians prescribed inhalational or bronchodilator therapy prior to 2009. Indeed, subsequent to the April 1999 PFT, medical records continuously demonstrate that the Veteran did not use or report using a bronchodilator to treat his respiratory symptoms. At the Veteran’s December 2005 examination, the examiner specifically reported that the Veteran did not use an inhaler or any other regular medications for bronchitis. While the Veteran may have benefited from taking medicine to treat his disability, it was neither required by a doctor nor actually taken. The Board acknowledges that on May 7, 2009, the Veteran saw a respiratory therapist through the Indianapolis VA Medical Center. The purpose of the visit was to educate the Veteran on using a respiratory inhaler. It is unclear why, after that visit, the Veteran would once again be prescribed a respiratory inhaler some four months later. Resolving all reasonable doubt in the Veteran’s favor, however, it appears that inhalation bronchodilator therapy was first prescribed at that May 2009 visit. Accordingly, the award of the 10 percent rating should be effective as of the date of May 7, 2009. As was noted above, the Veteran has not had any additional PFTs since May 2009. A review of the Veteran’s medical records show that the Veteran has continued to use an inhaler on an intermittent basis and the prescription has not escalated to daily use. See, e.g., October 2016, January 2017, August 2017 VA medication notes stating, “Albuterol as needed.” Furthermore, there is no evidence of record at any point during the claim period that the Veteran has required at least monthly visits to a physician for care of exacerbations, or that the Veteran has been prescribed courses of systemic corticosteroids or immuno-suppressive medications to treat his respiratory systems. Accordingly, a rating in excess of 10 percent under Diagnostic Code 6602 is not warranted at any time since May 7, 2009. REMANDED ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include bipolar disorder, cyclothymia, generalized anxiety disorder, and obsessive compulsive disorder is remanded. The Veteran first filed a claim for entitlement to service connection for cyclothymia in October 1997. Medical evaluations from the time of the initial claim incorporated numerous potential diagnoses of the Veteran’s psychiatric condition. These evaluations also suggested that the condition pre-existed the Veteran’s service, as indicated by the Veteran’s description of his medical and psychiatric history. In a July 1998 rating decision, the AOJ, looking at the totality of the medical evidence, determined that the Veteran’s psychiatric disorders pre-existed service and were not aggravated beyond their natural progression by service. A veteran will be considered to have been in sound condition upon entry to service, except as to defects, infirmities, or disorders noted at entrance, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding, supported by clear and unmistakable evidence (obvious or manifest) that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a), (b). To date, the evaluations of the Veteran’s psychiatric disorders have not conformed to the standards above. The Board first notes that the Veteran’s examination upon enlistment to active duty service does not record a pre-existing acquired psychiatric disorder, therefore the Veteran must initially be presumed sound unless the presumption can be rebutted. Post-service, the Veteran has received numerous diagnoses that have changed over time: cyclothymia, bipolar disorder, affective disorder, obsessive compulsive disorder, and personality disorder. The Board has therefore recharacterized the Veteran’s multiple claims as a claim of entitlement to service connection for any acquired psychiatric disorder. See, Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Board notes that this recharacterization was also requested by the Veteran’s representative in a July 2018 correspondence. On remand, an examination should be scheduled to assess the nature and etiology of his psychiatric disabilities. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination. The examiner should review the entire claims file. The examiner should take a history from the Veteran as to the progression of his symptoms. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should clearly identify all currently diagnosed acquired psychiatric disorders. If the examiner rules out a previously-diagnosed acquired psychiatric disorder, the examiner should explain the reasoning for that conclusion. The examiner should then provide responses to each of the following questions: a) For each psychiatric disability identified, is it clear and unmistakable (i.e. undebatable) that such disability pre-existed service? b) If the answer to question (a) is “yes,” is it also clear and unmistakable (i.e. undebatable) that such disability was NOT aggravated beyond its natural progression during his period of active duty service? In responding to this question, the examiner should consider not only the Veteran’s service treatment records, but also the Veteran’s lay assertions of symptom progression. c) For any disability where the answer to either question (a) or (b) is “no,” assume as true that the Veteran entered service in sound condition with respect to that disability. With this assumption in mind, is it at least as likely as not (50 percent or greater probability) that such disability had its onset in, or is otherwise related to the Veteran’s period of active service? The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. 2. Once the aforementioned development has been achieved, as well as any other development deemed necessary thereafter, readjudicate the appeal. If any benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Giaquinto, Associate Counsel