Citation Nr: 18161280 Decision Date: 12/31/18 Archive Date: 12/31/18 DOCKET NO. 16-43 948 DATE: December 31, 2018 ORDER New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure, is granted. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. A disability rating in excess of 10 percent for cystic acne, claimed as dermatitis, and lesions of the back and legs, is denied. A disability rating in excess of 50 percent for body dysmorphic disorder is denied. REMANDED Entitlement to service connection for diabetes mellitus, to include as due to medication treatment for acne and herbicide exposure. Entitlement to service connection for a right wrist impairment. Entitlement to service connection for a left wrist impairment. Entitlement to a total disability rating based on individual unemployability (TDIU). FINDINGS OF FACT 1. A June 2003 rating decision denied entitlement to service connection for diabetes mellitus; the Veteran did not timely appeal the denial and new and material evidence was not submitted within the one-year appeal period following the rating decision. 2. Evidence received since the June 2003 rating decision is new and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for diabetes mellitus. 3. The probative, competent evidence does not demonstrate that a right knee disability, to include arthritis, is related to active service, or that it manifested to a compensable degree within one year of separation from active service. 4. The probative, competent evidence does not demonstrate that a left knee disability, to include arthritis, is related to active service, or that it manifested to a compensable degree within one year of separation from active service. 5. During the period on appeal, the Veteran’s service-connected acne was, at its most severe, manifested by acne affecting less than 40 percent of the face and neck. 6. For the entire period on appeal the Veteran’s service-connected body dysmorphic disorder has been, at its most severe, manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The June 2003 rating decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 3.156 (b), 20.200, 20.202, 20.302, 20.1103 (2018). 2. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for diabetes mellitus is reopened. 38 U.S.C. §§ 1110, 1131, 5108 (2012); 38 C.F.R. §§ 3.156 (a), 3.303 (2018). 3. The criteria of entitlement to service connection for right knee arthritis have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2018). 4. The criteria of entitlement to service connection for left knee arthritis have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2018). 5. The criteria for a disability rating in excess of 10 percent for cystic acne have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-7806, 7828 (2018). 6. The criteria for a disability rating in excess of 50 percent for body dysmorphic disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1972 to September 1975. The issues of entitlement to increased ratings and a TDIU come to the Board on appeal from a November 2015 rating decision. The other issues come to the Board on appeal from a May 2015 rating decision. New and Material Evidence In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. An exception to this rule is provided in 38 U.S.C. § 5108, which states that if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The question of whether new and material evidence has been received to reopen a previously denied claim must be addressed by the Board in the first instance because the issue goes to the Board’s jurisdiction to reach and adjudicate the underlying claim on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and further analysis beyond consideration of whether the evidence received is new and material is neither required nor permitted. Barnett, 83 F.3d at 1384. New evidence is existing evidence not previously considered by VA. Material evidence is 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). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). The RO last denied service connection for diabetes in June 2003, because new and material evidence had not been received to reopen a May 2000 denial based on a lack of connection between the Veteran’s current disability and his in-service findings related to diabetes. The Veteran did not file a notice of disagreement with the June 2003 rating decision and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of issuance of notice of the rating decision. See 38 C.F.R. § 3.156 (b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). Thus, the June 2003 rating decision became final based on the evidence then of record. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. § 20.1105. The RO denied the reopening of the claim for service connection in a May 2015 rating decision, which forms the basis of the current appeal. The Veteran’s September 2014 claim stated that his current diabetes is related to exposure to herbicide agents while serving in Vietnam. The United States Court for Veterans Claims (Court) has held that the law should be interpreted as enabling reopening of a claim, rather than to precluding it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The focus is not exclusively on whether evidence remedies the principal reason for denial in the last prior final decision, but on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Id. at 118. Generally, a new theory of entitlement does not in and of itself constitute a new claim. See Ashford v. Brown, 10 Vet. App. 120, 123 (1997). However, the Board finds that the Veteran’s statements that his diabetes is related to exposure to herbicide agents is new in that it was not previously considered by VA. It is also material because it provides evidence that relates to an unestablished fact necessary to substantiate the claim, that is it provides new evidence of an in-service disease, injury, or event. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). As such, the Veteran’s statement raises a reasonable possibility of substantiating the claim. Accordingly, the Board finds that new and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for diabetes mellitus, and the claim is reopened. 38 C.F.R. § 3.156 (a). Service Connection To establish service connection for a disability on a direct-incurrent basis, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). See also 38 C.F.R. § 3.303. Service connection may also be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Arthritis is such a chronic disease under VA regulations. 1. Service connection for bilateral knee disabilities is denied. The Veteran contends that he fell off a ladder in service, hitting his knees on a vehicle, and that he was treated with pain medication. He reported taking medication as needed after service and was able to work construction with mild pain. With regard to the current disability element of Shedden, the record shows a 2013 diagnosis of mild bilateral degenerative arthritis. Thus, the Veteran has current knee disabilities. With regard to the second Shedden element, the Veteran’s service treatment records do show treatment of a knee, although the record is not dated, and it is unclear which knee was treated. An ace-wrap and hot pack were recommended, and no subsequent treatment of the knee was documented. The separation examination did not show complaints of knee problems. The Veteran attended a VA examination in April 2015 to determine the nature and etiology of his current knee disabilities. The examiner noted that 2002 and 2009 bilateral knee imaging was negative. The examiner opined that mild degenerative joint disease and patellofemoral syndrome of the bilateral knees was less likely than not incurred in or caused by the claimed in-service injury. The examiner noted that the service treatment records only showed the singular instance of knee pain, in one knee and that the separation and PEB examinations were negative for knee symptoms. The examiner noted that medical records are absent knee symptoms until 2002, which is over 20 years after service. The examiner also observed that all imaging was negative until 2013. Finally, the examiner opined that the knee disabilities are more than likely due to post-military jobs involving construction and carpentry, despite the Veteran’s contention that there has been no post-service injury. To the extent the Veteran contends his current disability is related to service, it is well established that a layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a)(1). In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). However, as the origin or cause of degenerative joint disease of the knees is not a simple question that can be determined based on personal observation by a lay person, the Veteran's lay statements are not competent to establish medical etiology or nexus. Id. As such, the Board finds the question of whether the Veteran's current degenerative joint disease of the knees had its onset during active duty does not lie within the range of common experience or common knowledge but requires special experience or special knowledge. It is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to the etiology of his degenerative joint disease of the knees. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Further, the Veteran’s contentions are not supported by the competent medical evidence of record. The medical evidence of record also does not show that the Veteran had complaint, treatment, or diagnosis of a chronic disability, such as arthritis, during service or within a year of separation. The first post-service complaints of knee problems were in 2002, over 20 years after service. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Therefore, service connection is not warranted on a presumptive basis under the provisions of 38 C.F.R. §§ 3.303 (b), 3.307, and 3.309. The Board acknowledges the evidence submitted that suggests arthritis can be slow in progression and that imaging is unreliable in diagnosis. However, the Board affords greater probative weight to the opinion of the skilled medical professional who personally examined the Veteran’s individual circumstances and symptoms. Further, the Board has considered the assertions of record that the Veteran’s knee condition is related to his acne due to the possibility of SAPHO syndrome. However, a claim for secondary service-connection is based on the proximate relationship to or aggravation of a current disability to or by a service-connected disability. The evidence submitted to the Board regarding SAPHO syndrome suggests that acne and arthritis are symptoms of SAPHO. The Veteran is not service-connected for SAPHO, and there is no claim for service-connection for SAPHO before the Board. Moreover, the evidence submitted does not raise the issue of secondary service connection as there is no assertion that acne is the cause of the Veteran’s arthritis. In summary, the most probative evidence of record does not support a finding that it is at least as likely as not that there is a causal relationship between the Veteran’s current bilateral knee arthritis and his military service. In light of the above, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. The claim therefore must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999).] 2. A disability rating in excess of 10 percent for cystic acne, claimed as dermatitis, and lesions of the back and legs, is denied. The Veteran’s service-connected acne is rated as 10 percent disabling under Diagnostic Code 7828, effective from March 3, 2000. The applicable rating period is from up to one year prior to August 5, 2015, the date the Board received the claim for increase. Under Diagnostic Code 7828, a noncompensable disability rating is warranted for superficial acne (comedones, papules, pustules, superficial cysts, of any extent. A 10 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or; deep acne other than on the face and neck. The maximum 30 percent disability rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. Acne may be rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, 7805), depending upon the predominant disability. The most recent VA examination in October 2016 found generalized superficial scarring of the forehead and cheeks, measuring .1 cm by .3 cm each. There was no missing tissue, and no limitation of function. It was noted that none of the facial scars were painful or unstable. Examination also revealed diagnoses of acne and neurotic excoriation and prurigo nodularis, the latter of which was found during VA treatment in 2015 but not on the current examination. The Veteran reported weekly cystic lesions, taking a few days to heal, and he washes his face several times a day. The examiner noted that there was presence of unstable or painful scars or disfigurement, and that they were of the head, face, or neck. The examiner described the skin condition as superficial acne with no active lesions. A November 2015 addendum opinion to a September 2015 VA examination noted that scars were not painful, but that cysts and acne could be painful when inflamed. It was noted that the Veteran picked at his acne. The September 2015 examination noted that less than 5 percent of total or exposed body area was impacted. The Veteran submitted a private evaluation dated May 1, 2017 that indicated that the Veteran should be entitled to a 30 percent evaluation under Diagnostic Code 7800 due to 3 characteristics of disfigurement. Specifically, the examiner noted that a review of photos, taken in May 2017, showed a scar of at least 1 quarter inch width, surface contour of scar elevated or depressed on palpation, and skin hypo- or hyper-pigmented in an area exceeding six square inches. The May 2017 opinion was not formed via in person or video examination, as were the VA examinations of record. The May 2017 examiner indicated that the Veteran had a characteristic of disfigurement manifested by elevation or depression on palpation, but the examiner did not physically examine the Veteran. Further, the examiner stated that her opinion was based on photographs taken in May 2017, which were attached to her report. However, the same photographs were attached to the May 2017 private report received by the Board in September 2016 and were available to the October 2016 VA examiner. Given the above, the Board affords greater probative weight to the findings of the multiple VA examiners who examined the Veteran, as well as the findings reflected in the VA dermatology records during the period on appeal, which are largely consistent with the VA examinations. Consideration has also been given to assigning higher ratings under an alternative Diagnostic Code. See 38 C.F.R. § 4.118; Diagnostic Codes 7800-7805 (2018). However, Diagnostic Code 7828 explicitly states that acne should be rated according to the area affected, or rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Code 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. The regulation’s use of the disjunctive indicates that separate ratings are not to be assigned under Diagnostic Codes 7800 through 7805 and Diagnostic Code 7828. The Board finds that the record reflects the Veteran’s disability is predominantly manifest by acne, and the record does not show 3 characteristics of disfigurement, a disability predominantly manifest by unstable or painful scars, tissue loss, or a condition impacting 20 to 40 percent of the body. The record does not show deep acne affecting 40 percent or more of the face and neck. The Board has also considered the statements of the Veteran as to the extent of his skin symptoms, but more weight is given to the competent findings of medical professionals. In light of the above, the preponderance of the evidence is against the claim. The benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. A disability rating in excess of 50 percent for body dysmorphic disorder is denied. The Veteran’s service-connected body dysmorphic disorder is rated as 50 percent disabling under 38 C.F.R. § 4.130, effective from May 23, 2003. The applicable rating period is from up to one year prior to August 5, 2015, the date of receipt of the Veteran’s claim for increase. Under Diagnostic Code 9434, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. A maximum 100 percent evaluation is for application when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The Veteran attended a VA examination in September 2015 to determine the severity of his mental health condition. The examiner opined that the Veteran’s mental health condition was manifested by reduced reliability and productivity. The examiner found a marked preoccupation with his facial appearance, which was noted as a largely imagined defect. Occupational and social defect was described as moderate. The Veteran was married, and had contact with family, but no close friends. Symptoms included depression, anxiety, difficulty with relationships and stressful circumstances, and poor sleep. The Veteran was also mildly irritable. He had normal speech processes, no recurrent panic attacks, adequate grooming, and no suicidal ideation. The September 2015 VA examination is largely consistent with the other medical evidence of record. The July 2017 correspondence from the Veteran’s representative contends that additional mental health symptoms were established in the narrative of the VA examinations of record. The correspondence asserts that the most recent VA examination showed thoughts of suicide, delusions, thoughts of homicide, and long and short-term memory impairment, among other symptoms. However, those symptoms are not detailed anywhere in the September 2015 examiner’s report. Indeed, the medical evidence of record does not show an impairment in most areas or total occupational and social impairment. The Veteran has family relationships and completes his daily activities. As such, the record does not show that the Veteran’s dysmorphic disorder warranted a disability rating in excess of 50 percent at any time during the period on appeal. The Board has considered the Veteran’s contentions that he is entitled to a higher rating. The Veteran is competent to report symptoms of his mental health condition, as doing so requires only personal knowledge. See Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran is also credible in his belief that he is entitled to a higher initial rating. However, the Veteran is not competent to render an opinion as to the relative severity of his condition, as doing so requires specialized medical knowledge or expertise the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006). The Board concludes that, given the medical professionals’ expertise in evaluating mental disorders, the findings of record provided by the medical professionals are more probative than the Veteran’s statements. As discussed above, the clinical evidence of record supports a finding that a rating in excess of 50 percent is not warranted for the Veteran’s service-connected body dysmorphic disorder at any time during the period on appeal. In light of the above, the Board finds that a disability rating in excess of 50 percent is not warranted, the preponderance of the evidence is against the appeal, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2018) (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).] REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus, to include as due to medication treatment for acne and herbicide exposure. The Veteran contends that he had diabetes mellitus diagnosed on active duty and that his diabetes mellitus was caused or aggravated by his treatment with steroids for service-connected acne. A July 2017 correspondence from the Veteran’s representative contends that the Veteran’s in-service steroid treatment for acne created a susceptibility to diabetes mellitus. The record reflects that the Veteran was treated with steroids for his acne in service. The record contains multiple VA opinions distinguishing the Veteran’s in-service diagnosis from his current diagnosis. The record also contains sufficient information to address the Veteran’s contentions that his diabetes was due to exposure to herbicides. However, the only competent medical opinion of record associated with the Veteran’s diabetes mellitus was aggravated by his medication treatment for acne is a January 2006 VA opinion. However, that examination was provided as part of development for the Veteran’s claim for compensation under 38 U.S.C. § 1151, which alleged that steroid and B12 deficiency treatment by the VA caused or aggravated his diabetes. Thus, an addendum opinion is necessary on remand to address whether it is at least as likely as not that the Veteran’s diabetes was aggravated by his in-service acne treatment. 2. Entitlement to service connection for a bilateral wrist impairment. The Veteran attended a VA examination in April 2015 to determine the nature and etiology of his bilateral wrist condition. The examiner provided an opinion that the Veteran’s bilateral carpal tunnel syndrome was less likely than not related to service. The Board finds the examiner’s opinion inadequate for decision-making purposes. An opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The examiner’s rationale noted that “all post-military records [are] negative for numbness/wrist symptoms until 2004.” However, the examiner did not address evidence from October 1998 of hand cramps and from the Spring of 2000 of tingling in the fingers. As there is evidence of possible post-service carpal tunnel symptomatology prior to 2004, an addendum opinion must be obtained. 3. Entitlement to a TDIU. The issue of entitlement to a TDIU must be remanded as it is inextricably intertwined with the claims of entitlement to service connection for diabetes and wrist impairment. Any grant of service connection may directly impact the Veteran’s eligibility on a schedular basis. As such, the TDIU adjudication must be deferred until development is complete with regard to the Veteran’s other remanded claims. The matters are REMANDED for the following action: 1. Associate with the claims file any outstanding, relevant treatment notes. 2. Forward the record and a copy of this remand to an appropriate examiner for completion of an opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus is proximately due to or aggravated by his service-connected acne disability. In particular, the examiner should address whether the Veteran’s in-service treatment aggravated his current condition. Aggravation is defined as a permanent worsening beyond the natural progression of the disease. A complete rationale should accompany any conclusion reached. 3. Forward the record and a copy of this remand to the examiner who conducted the April 2015 VA wrist examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s wrist disabilities were incurred in or caused by service. The examiner should address the Veteran’s post-service hand and finger complaints prior to 2004. A complete rationale should accompany any conclusion reached. 4. If the evidence reflects that the Veteran was unable to obtain or maintain substantially gainful employment due to service-connected disabilities, but his combined rating for that period does not meet the schedular criteria for a TDIU, the RO should refer the appeal to the Director of Compensation Service for extra-schedular consideration of the issue of entitlement to TDIU. (Continued on the next page)   5. After completion of the above, review the expanded record, including the evidence entered since the most recent supplemental statement of the case, and determine whether the benefits sought may be granted. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. K. M. SCHAEFER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Baker, Associate Counsel