Citation Nr: 1807374 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 14-07 991 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for a back disorder. 2. Entitlement to service connection for a back disorder. 3. Whether new and material evidence has been received to reopen service connection for a bilateral foot disorder. 4. Entitlement to service connection for a bilateral foot disorder. 5. Entitlement to service connection for an acquired psychiatric disorder. 6. Entitlement to an increased disability rating (or evaluation) in excess of 10 percent for alopecia areata. 7. Entitlement to an increased disability rating (or evaluation) in excess of 40 percent for post-operative varicose veins of the left leg. REPRESENTATION Representative: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD E. Blowers, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from March 1958 to June 1962. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the RO in St. Louis, Missouri. The Veteran testified from San Diego, California, at a May 2017 Board videoconference hearing before the undersigned Veterans Law Judge, who was seated in Washington, DC. The hearing transcript has been associated with the record. At the May 2017 Board videoconference hearing, the Veteran and representative requested a 90 day extension to submit additional evidence, which was granted. Subsequently, in July 2017, the Veteran requested additional time to obtain relevant records from treating physicians. In a subsequent September 2017 letter, the undersigned Veterans Law Judge granted an additional 90 day extension to submit evidence. To date, no new evidence has been received from the Veteran or representative; however, as the majority of the issues on appeal are either being granted or remanded, and as there is sufficient evidence of record to decide the alopecia areata rating issue, the Board finds the instant matter ripe for adjudication. The instant matter is a Veterans Benefits Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2012) and 38 C.F.R. § 20.900(c) (2017). The issue of service connection for a bilateral foot disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Per the Veteran's May 2017 Board videoconference hearing testimony, prior to the promulgation of a Board decision in the present appeal, the Veteran asked to withdraw the issue of an increased disability rating in excess of 40 percent for post-operative varicose veins of the left leg. 2. A January 1990 RO rating decision denied service connection for a back disorder, finding no in-service injury and no aggravation of preexisting scoliosis. The Veteran filed a timely notice of disagreement (NOD) following the January 1990 rating decision, but did not perfect the appeal after the issuance of an April 1990 SOC. No new and material evidence was received during the one year appeal period following the January 1990 rating decision. 3. A June 2002 RO rating decision denied reopening of service connection for a back disorder. The Veteran did not file a timely NOD following the June 2002 rating decision, and no new and material evidence was received during the one year appeal period following that decision. 4. In June 2006, the RO again denied reopening of service connection for a back disorder. The Veteran did not file a timely NOD following the June 2006 rating decision, and no new and material evidence was received during the one year appeal period following that decision. 5. New evidence received since the June 2006 rating decision reflects a new diagnosis of back disorder not previously considered by the RO that could substantiate the claim for service connection for a back disorder. 6. A January 1991 RO rating decision denied service connection for a bilateral foot disorder, finding no nexus between the Veteran's diagnosed bilateral pes planus and service. The Veteran did not file a timely NOD following the January 1991 rating decision, and no new and material evidence was received during the one year appeal period following that decision. 7. A June 2002 RO rating decision denied reopening of service connection for a bilateral foot disorder. The Veteran did not file a timely NOD following the June 2002 rating decision, and no new and material evidence was received during the one year appeal period following that decision. 8. In June 2006, the RO again denied reopening of service connection for a bilateral foot disorder. The Veteran did not file a timely NOD following the June 2006 rating decision, and no new and material evidence was received during the one year appeal period following that decision. 9. New evidence received since the June 2006 rating decision reflects a new diagnosis of bilateral foot disorder not previously considered by the RO, which could substantiate the claim for service connection for a bilateral foot disorder. 10. The Veteran is currently diagnosed with arthritis of the thoracolumbar spine. 11. During service the Veteran was treated for back pain related to in-service duties as nurse. 12. The Veteran experienced "continuous" symptoms of arthritis of the thoracolumbar spine since service separation. 13. The Veteran is currently diagnosed with an anxiety disorder. 14. During service the Veteran experienced sexual and racial harassment. 15. The currently diagnosed anxiety disorder is related to the in-service sexual and racial harassment. 16. For the entire increased rating period on appeal, the Veteran's service-connected alopecia areata did not manifest as scarring alopecia affecting more than 40 percent of the scalp. CONCLUSIONS OF LAW 1. The criteria for the withdrawal of a substantive appeal have been met regarding the appeal for an increased disability rating in excess of 40 percent for post- operative varicose veins of the left leg. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 2. The January 1990, June 2002, and June 2006 rating decisions denying service connection or reopening of service connection for a back disorder became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 3. Evidence received since the June 2006 rating decision is new and material to reopen service connection for a back disorder. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 4. The January 1991, June 2002, and June 2006 rating decisions denying service connection or reopening of service connection for a bilateral foot disorder became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 5. Evidence received since the June 2006 rating decision is new and material to reopen service connection for a bilateral foot disorder. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for presumptive service connection for arthritis of the thoracolumbar spine have been met. 38 U.S.C. §§ 1101, 1112, 1131, 1133, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a) (2017). 7. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for an acquired psychiatric disorder of anxiety disorder have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326 (2017). 8. For the entire rating period on appeal, the criteria for an increased disability rating for alopecia areata in excess of 10 percent have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.118, Diagnostic Code 7830-7831. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal of Varicose Veins Rating Under 38 U.S.C. § 7105, the Board may dismiss any appeal that fails to allege a specific error of fact or law in the determination being appealed. A veteran may withdraw a substantive appeal by telling the Board of the decision to withdraw either in writing or on the record at a Board personal hearing. 38 C.F.R. § 20.204. Per the Veteran's May 2017 Board videoconference hearing testimony, prior to the promulgation of a Board decision in the present appeal, the Veteran asked to withdraw the issue of an increased disability rating in excess of 40 percent for post-operative varicose veins of the left leg. As the Veteran has withdrawn the appeal regarding this issue, there remain no allegations of errors of fact or law for appellate consideration as to this issue. See 38 U.S.C. § 7104 (2012). Accordingly, the Board does not have jurisdiction to review the issue of an increased disability rating in excess of 40 percent for post-operative varicose veins of the left leg, and the issue will be dismissed. Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. As the instant decision reopens and grants service connection for a back disorder, reopens and remands service connection for a bilateral foot disorder, and grants service connection for an acquired psychiatric disorder, no further discussion of VA's duties to notify and assist is necessary as to those issues. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In January 2008, VA issued the Veteran VCAA notice that informed of the evidence generally needed to support a claim for an increased disability rating, what actions the Veteran needed to undertake, and how VA would assist in developing the claim. The January 2008 VCAA notice was issued to the Veteran prior to the April 2008 rating decision on appeal. Further, the issues on appeal were readjudicated in a January 2014 statement of the case (SOC) and an April 2014 supplemental statement of the case (SSOC); therefore, there was no defect with respect to the timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the duty to assist in this case, the Veteran received multiple VA alopecia areata examinations during the course of this appeal. The examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The record reflects that, taken together, the VA examiners reviewed the record, conducted in-person examinations, and rendered the requested opinions. A veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95. At the May 2017 Board videoconference hearing, the Veteran's representative conveyed that they would be submitting evidence that the alopecia areata had worsened if, after review, the Veteran's representative decided it would be "worth me submitting that evidence." See May 2017 Board hearing transcript at p. 5. To date, the Board has not received any additional evidence from the Veteran or representative concerning the alopecia areata. Having reviewed all the relevant evidence of record, the Board does not find that the evidence of record indicates any worsening since the last VA alopecia areata examination. As such, the Board does not find remand for a new VA alopecia areata examination to be warranted. All relevant documentation, including VA and private treatment (medical) records, has been secured, or attempted to be secured, and all relevant facts have been developed. There remains no question as to the substantial completeness of the remaining issues on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Reopening Service Connection for Back and Foot Disorders Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C. § 7105. However, pursuant to 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as 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 new evidence must 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 received 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, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Regardless of the RO's determination as to whether new and material evidence had been received, the Board must address the issue of the receipt of new and material evidence in the first instance because it determines the Board's jurisdiction to reach the underlying claims and to adjudicate the claims de novo. See Woehlaert v. Nicholson, 21 Vet. App. 456, 460-61 (2007) (citing Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996)). If the Board determines that the evidence submitted is both new and material, it must reopen the case and evaluate the claim in light of all the evidence. Justus, 3 Vet. App. at 512. Such evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Id. at 513. In order to prevail on the issue of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). A January 1990 RO rating decision denied service connection for a back disorder, finding no in-service injury and no aggravation of preexisting scoliosis. The Veteran filed a timely NOD following the January 1990 rating decision, but did not perfect the appeal after the issuance of an April 1990 SOC. Further, no new and material evidence was received during the one year appeal period following the January 1990 rating decision. Subsequently, a June 2002 RO rating decision declined to reopened the issue of service connection for a back disorder. The Veteran did not file a timely NOD following the June 2002 rating decision, and no new and material evidence was received during the one year appeal period following that decision. Then, in June 2006, the RO again declined to reopen the issue of service connection for a back disorder. The Veteran did not file a timely NOD following the June 2006 rating decision, and no new and material evidence was received during the one year appeal period following that decision. As such, the January 1990, June 2002, and June 2006 rating decisions became final as to the evidence then of record, and are not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b), 20.302, 20.1103. Additionally, a January 1991 RO rating decision denied service connection for a bilateral foot disorder, finding no nexus between the Veteran's diagnosed bilateral pes planus and service. The Veteran did not file a timely NOD following the January 1991 rating decision, and no new and material evidence was received during the one year appeal period following that decision. Subsequently, a June 2002 RO rating decision declined to reopened the issue of service connection for a bilateral foot disorder. The Veteran did not file a timely NOD following the June 2002 rating decision, and no new and material evidence was received during the one year appeal period following that decision. Then, in June 2006, the RO again declined to reopen the issue of service connection for a bilateral foot disorder. The Veteran did not file a timely NOD following the June 2006 rating decision, and no new and material evidence was received during the one year appeal period following that decision. As such, the January 1991, June 2002, and June 2006 rating decisions became final as to the evidence then of record, and are not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b), 20.302, 20.1103. Since the June 2006 rating decision declining to reopen the issues of service connection for back and foot disorders, VA has received the reports from various VA examinations. Per the report from a December 2012 VA spinal examination, X-ray imaging showed arthritis in the thoracolumbar spine. Further, a March 2011 VA foot examination report noted that the Veteran was diagnosed with bilateral arthritis of the feet. Such new diagnoses could substantiate the claims for service connection for back and foot disorders. As such, the Board finds that the additional evidence is new and material to reopen service connection for back and bilateral foot disorders. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection Law and Regulation Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden, 381 F.3d 1163; see also Hickson, 12 Vet. App. at 253, citing Caluza, 7 Vet. App. at 506. Arthritis is a chronic disease under 38 C.F.R. § 3.309(a). As such, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to the issue of service connection for a back disorder. Walker, 708 F.3d 1331. Anxiety disorder is not a chronic disease under 38 C.F.R. § 3.309(a), and the presumptive service connection provisions under 38 C.F.R. § 3.303(b) do not apply. Id. Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338-40 (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a) (2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection for a Back Disorder The Veteran asserts that a currently diagnosed back disorder is related to duties performed as a nurse during service. It has been the Veteran's contention that the back pain has continued from service separation to the present. Initially, the Board finds that the Veteran is currently diagnosed with arthritis of the thoracolumbar spine. The report from a December 2012 VA back examination reflects that X-ray imaging showed arthritis in the thoracolumbar spine. Next, the Board finds that during service the Veteran was treated for back pain related to in-service duties as nurse. Service treatment records reflect that during service the Veteran complained of, and sought treatment for, back pain. Per the report from the December 2012 VA back examination, the Veteran advanced that the in-service back pain was due to lifting injuries. A November 2009 private treatment letter from the Veteran's VA physician explained that the Veteran would injure the back while lifting patients as part of in-service nursing duties. While the VA physician did not render a specific opinion, the physician did note that there was a strong possibility the Veteran's back pain was related to the type of lifting required as a nurse. At a February 2010 Decision Review Officer (DRO) hearing, the Veteran also testified about back pain related to lifting heavy patients. Having reviewed all the evidence of record, lay and medical, the Board finds that the weight of the evidence is at least in equipoise on the question of whether the Veteran experienced "continuous" symptoms since service separation of arthritis of the thoracolumbar spine to meet the requirements for presumptive service connection for the chronic disease of arthritis. See 38 C.F.R. § 3.303(b). As noted above, the Veteran was treated for complaints of back pain during service. Review of the extensive medical evidence of record reflects that the Veteran has sought treatment for back pain since at least the 1980s, with the November 2009 VA treatment letter noting that the Veteran had been receiving treatment at VA since the 1970s. Per the report from the December 2012 VA back examination, the Veteran advanced that the back pain progressed both during and after service without any additional trauma. In the November 2009 VA treatment letter, the VA physician noted that the Veteran had conveyed a long history of back pain dating back to service. While the Veteran did not specifically testify about continuous back disorder symptoms at the February 2010 DRO hearing or the May 2017 Board videoconference hearing, the Board notes that at these hearings the testimony focused on aggravation of the Veteran's scoliosis, with no consideration of the more recently diagnosed arthritis. As such, the hearings did not focus on any questions of continuing symptomatology. Further, while the Veteran was diagnosed with arthritis at the December 2012 VA back examination, no opinion was rendered as to whether the currently diagnosed arthritis of the thoracolumbar spine was related to the in-service lifting of heavy patients as part of in-service nursing duties. The Veteran is currently diagnosed with arthritis of the thoracolumbar spine. During service the Veteran was treated for back pain related to in-service duties as a nurse. Throughout the course of this appeal, the Veteran has advanced having back disability symptoms during and after service, and the available medical evidence of record is consistent with the Veteran's lay statements. This evidence is sufficient to place in equipoise the question of whether the Veteran experienced continuity of symptomatology of a back disorder since service separation that was later diagnosed as arthritis of the thoracolumbar spine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (a veteran is competent to testify regarding continuous joint pain since service). Resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran was treated for back pain during service related to nursing duties and experienced "continuous" symptoms since service separation of arthritis of the thoracolumbar spine. As such, the criteria for presumptive service connection for arthritis of the thoracolumbar spine under 38 C.F.R. § 3.303(b) based on "continuous" post-service symptoms have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As service connection is being granted on a presumptive basis based on continuous post-service symptoms under 38 C.F.R. § 3.303(b), there is no need to discuss entitlement to service connection on a direct or any other basis as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104. Finally, the Board notes that the evidence of record indicates that the Veteran is diagnosed with other back disorders, to include scoliosis. Where a veteran is diagnosed with multiple back (spinal) disorders, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam). In this case, the Board is unable to differentiate the symptomatology of the now service-connected arthritis of the thoracolumbar spine from any other back disorders. As such, the Board has attributed all disability symptomatology and functional impairment to the now service-connected arthritis of the thoracolumbar spine, and the RO should consider all of the Veteran's thoracolumbar spine symptomatology and functional impairment when assigning an initial disability rating. For these reasons, the Board need not consider whether service connection is also warranted for any other back disorders. Service Connection for an Acquired Psychiatric Disorder The Veteran asserts that a currently diagnosed acquired psychiatric disorder is related to sexual and racial harassment experienced during service. Per a July 2012 VA mental health examination report, while the Veteran did not meet the criteria for a diagnosis of posttraumatic stress disorder (PTSD), the Veteran did have the acquired psychiatric disorders of anxiety disorder and depression. Next, the Board finds that during service the Veteran experienced sexual and racial harassment. Without getting into the vulgar details, in testimony at the February 2010 DRO hearing and at the May 2017 Board videoconference hearing, and in multiple lay statements throughout the course of this appeal, the Veteran has advanced experiencing multiple instances of sexual and racial harassment during service while working as a nurse. While service records do not reflect that the harassment was reported, at the February 2010 DRO hearing, the Veteran testified to attempting to report the harassment when it first began, but gave up when it became clear that nobody was taking the reports seriously. At the February 2010 DRO hearing, and elsewhere throughout the record, the Veteran testified that the sexual and racial harassment led to a request for early discharge. Per the Veteran's testimony, not only was the early release denied, but service was also involuntarily extended due to the Veteran previously going absent without leave (AWOL). Service personnel records reflect that in November 1961 the Veteran was rated as "very effective and reliable" in the performance of duties. The personnel records also show that in February 1962, the Veteran's enlistment was involuntarily extended due to AWOL status from January 31, 1962 to February 2, 1962. A subsequent May 1962 service personnel record reflects that the Veteran's performance of duties were found to be less effective after the involuntary extension of enlistment. The Board finds that the Veteran going from a service member who was "very effective and reliable" in the performance of duties, to one who went AWOL, had service involuntarily extended, and who then performed at an unsatisfactory level a mere six months later, supports a finding that the Veteran experienced and had a negative reaction to sexual and/or racial harassment during service. Finally, after a review of all the evidence of record, both lay and medical, the Board finds that the evidence is at least in equipoise as to whether the Veteran's currently diagnosed anxiety disorder is related to the in-service harassment. At the conclusion of the July 2012 VA mental health examination, after reviewing all the relevant evidence of record, the VA examiner opined that it was at least as likely as not that the currently diagnosed anxiety disorder was related to the in-service harassment. No opinion to the contrary has been received by VA. The Veteran is currently diagnosed with the acquired psychiatric disorder of anxiety disorder. During service the Veteran experienced sexual and racial harassment. A VA examiner has opined that the anxiety disorder is related to the Veteran's experiences during service. Resolving reasonable doubt in the Veteran's favor, the Board finds that the acquired psychiatric disorder of anxiety disorder was incurred in active service. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As noted above, the VA examiner at the July 2012 VA mental health examination also diagnosed the Veteran with depression. At the conclusion of the examination, the VA examiner opined that the depression was not related to the in-service harassment; however, the VA examiner also found that it was not possible to differentiate the symptoms of the anxiety disorder from the depression due to significant overlap of symptomatology. Where a veteran is diagnosed with multiple mental health disorders, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider, 11 Vet. App. at 182. As such, based upon the findings of the VA examiner in July 2012, the Board has attributed all mental health symptomatology and functional impairment to the now service-connected anxiety disorder, and the RO should consider all of the Veteran's mental health symptomatology and functional impairment when assigning an initial disability rating. For these reasons, the Board need not consider whether service connection is also warranted for any other acquired psychiatric disorder, to include depression. Increased Disability Rating for Alopecia Areata Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). Where there is a question as to which of two disability 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. 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. 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 (2017). Pyramiding, the rating 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 (2017). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Where an increase in an existing disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. The Board has thoroughly reviewed all the evidence in the Veteran's claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Alopecia areata is rated under Diagnostic Code 7831. 38 C.F.R. § 4.118. Under Diagnostic Code 7831, a noncompensable (0 percent) rating is warranted for alopecia areata manifested by loss of hair limited to scalp and face, while a 10 percent rating is warranted for loss of all body hair. Id. The Veteran's alopecia areata is currently rated as 10 percent disabling, which is the maximum rating available under Diagnostic Code 7831. As such, in the instant decision the Board considers whether an increased disability rating is warranted under Diagnostic Code 7830 for scarring alopecia. Under Diagnostic Code 7830, a noncompensable disability rating is warranted for scarring alopecia affecting less than 20 percent of the scalp, a 10 percent rating is warranted for scarring alopecia affecting 20 to 40 percent of the scalp, and a maximum 20 percent rating is warranted for scarring alopecia affecting over 40 percent of the scalp. Id. Having reviewed all the evidence of record, both lay and medical, the Board finds that, for the entire increased rating period on appeal, the Veteran's service- connected alopecia areata did not manifest as scarring alopecia affecting more than 40 percent of the scalp. The Board has received conflicting evidence concerning whether the Veteran has scarring alopecia. Further, the evidence indicating that the Veteran does have scarring alopecia is unclear as to whether the scarring alopecia is related to the service-connected alopecia areata; however, as the affirmative evidence of record reflects that any scarring alopecia does not affect more than 40 percent of the Veteran's scalp, the Board need not address the question of scarring alopecia versus alopecia areata at this time. An October 2007 VA treatment record noted non-scarring alopecia in temporal areas of the scalp. A September 2008 VA treatment record also diagnosed non-scarring alopecia. Per a June 2013 VA dermatology outpatient note, the Veteran's alopecia resulted in hair loss with apparent reduction in number of follicular ostia. There was also sparse hair loss of the posterior scalp and axillae. No mention of scarring was made. At the February 2010 DRO hearing, the Veteran testified to treating the alopecia with a special shampoo. No testimony as to the symptoms of the alopecia, to include the question of whether the Veteran had scarring, was offered. Further, at the May 2017 Board videoconference hearing, the Veteran did not testify about any symptoms related to the service-connected alopecia. Per the Veteran's representative, they were unsure whether the Veteran even had scarring alopecia. In a March 2010 lay statement, while the Veteran's ex-husband noted being aware of the Veteran's areas of hair loss to the scalp, no mention was made of any scarring. The Veteran received a VA alopecia examination in December 2009. Per the examination report, the Veteran was noted to have scarring, patchy alopecia. When asked to opine as to the percentage of scalp affected by scarring alopecia, the VA examiner opined "about 50 percent." A new VA alopecia examination was conducted in November 2011. At that time, the Veteran was diagnosed with both alopecia areata and "scarring alopecia secondary to lichen planopilaris." Per the examination report, the scarring alopecia covered 20 to 40 percent of the Veteran's scalp. At the conclusion of the examination, the VA examiner was unable to opine as to whether the scarring alopecia was related to, or a continuation of, the alopecia areata. Subsequently, another VA alopecia examination was performed in March 2014. Upon examination, the alopecia was found to be non-scarring. After having reviewed all the relevant evidence of record, the Board finds that, for the entire increased rating period on appeal, the Veteran's service-connected alopecia areata did not manifest as scarring alopecia affecting more than 40 percent of the scalp. The Board notes that the majority of the evidence indicates that the Veteran does not have scarring alopecia. While the VA examiner at the November 2011 VA alopecia examination did find that the Veteran had scarring alopecia (which may not even be related to the service-connected alopecia areata), the actual scarring area was found to be 20 to 40 percent of the scalp, which would not warrant an increased disability rating under Diagnostic Code 7830. 38 C.F.R. § 4.118. The Board notes that a VA examiner purported to find that the Veteran had scarring alopecia affecting "about 50 percent" of the Veteran's scalp at a December 2009 VA alopecia examination; however, the Board finds this opinion to be of little probative value, as the opinion ("about 50 percent") is a very general statement unsupported by other specific findings before and after this statement. Review of the December 2009 VA alopecia examination report does not convey that the "about 50 percent" opinion was based upon actual scalp measurements using proper measuring equipment. Rather, considering all the other evidence of record, it appears to the Board that the eyeballed reading of "about 50 percent" was more in line with an actual measurement of scalp scarring of 40 percent or less. The preponderance of the evidence of record, lay and medical, reflects that, for the entire increased rating period on appeal, the Veteran's service-connected alopecia areata did not manifest as scarring alopecia affecting more than 40 percent of the scalp to warrant an increased disability rating of 20 percent under Diagnostic Code 7830. 38 C.F.R. § 4.118. As the preponderance of the evidence is against the claim for an increased rating, the claim for an increased rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Codes 7830-31. Extraschedular Referral Consideration The Board has also considered whether referral for an extraschedular rating is warranted for the service-connected alopecia areata. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). However, the Board gives no deference to the Director's adjudication and the Board is permitted to exercise jurisdiction over the question of entitlement to an extraschedular rating whether or not the Director of the Compensation and Pension Service finds an extraschedular rating warranted. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015) (applying principles announced in Wages to 38 C.F.R. § 3.321(b) extraschedular adjudication, namely, Director of C&P decision is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board); Cf. Wages v. McDonald, 27 Vet. App. 233 (2015) (holding that a decision of TDIU under 38 C.F.R. § 4.16(b) by the Director of C&P is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). With respect to the first prong of Thun, the evidence in the instant appeal does not establish such an exceptional disability picture as to render the schedular rating criteria inadequate. Diagnostic Codes 7830 and 7831 rate alopecia based upon hair loss and scarring. As discussed above, the current symptomatology is contemplated by Diagnostic Codes 7830 and 7831, as the only symptoms shown by the Veteran were hair loss and (possible) scarring; therefore, as the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate under Diagnostic Codes 7830 and 7831. 38 C.F.R. § 4.118. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2017). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above. In the absence of exceptional factors associated with the Veteran's alopecia areata, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is potentially an element of all rating issues. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In August 2016, the RO sent the Veteran a SOC concerning the issue of entitlement to a TDIU, which had been denied in an August 2015 RO rating decision. The Veteran did not subsequently perfect the appeal concerning the previous denial of a TDIU. Further, a new claim for individual unemployability has not been raised by the Veteran or the evidence since the August 2015 RO rating decision became final; therefore, the Board finds that the issue of entitlement to a TDIU is not before the Board at this time. ORDER The appeal for an increased disability rating in excess of 40 percent for post-operative varicose veins of the left leg is dismissed. New and material evidence having been received, the appeal to reopen service connection for a back disorder is granted. Service connection for arthritis of the thoracolumbar spine is granted. New and material evidence having been received, the appeal to reopen service connection for a bilateral foot disorder is granted. Service connection for the acquired psychiatric disorder of anxiety disorder is granted. An increased disability rating in excess of 10 percent for the service-connected alopecia areata is denied. REMAND Outstanding Treatment Records VA should obtain all relevant VA and private clinical documentation that could potentially be helpful in resolving the issues. Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). At the May 2017 Board videoconference hearing, the Veteran's representative advanced that the Veteran's VA podiatrist, Dr. H, had "added additional evidence and will be adding more." Presumably, the representative was referring to VA foot treatment records that have not yet been added to the record. Further, the representative stated that Dr. H was "speaking to his supervisor," which would generate new evidence to support the foot issues on appeal. The Board notes that Dr. H may have been speaking to the supervisor about drafting a nexus opinion concerning any currently diagnosed foot disorders. As there are potentially outstanding and relevant VA foot treatment records, the Board finds remand warranted to obtain any recently generated VA foot treatment records not already of record. Service Connection for Bilateral Foot Disorder VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. Floyd v. Brown, 9 Vet. App. 88, 93 (1996). VA must afford a veteran a medical examination and/or obtain a medical opinion when it is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr, 21 Vet. App. at 312. While not having any specific foot injury during service, the Veteran believes that one or more currently diagnosed bilateral foot disorders are related to duties performed as a nurse during service. The Veteran received a sparse VA foot examination in March 2011. While the VA examiner diagnosed bilateral pes planus and arthritis of the feet, no nexus opinion was provided. Considering the sparseness of the exam, along with the lack of nexus opinion, the Board finds remand for a new VA foot examination to be warranted. Accordingly, the issue of service connection for a bilateral foot disorder is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and request information as to any outstanding private treatment (medical) records concerning the feet. Upon receipt of the requested information and the appropriate releases, the AOJ should contact all identified health care providers and request that they forward copies of all available treatment records and clinical documentation for the relevant time period on appeal pertaining to the treatment of the feet, not already of record, for incorporation into the record. If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e). 2. Associate with the record all VA treatment records pertaining to the treatment of the Veteran's feet, to include treatment by the Veteran's VA podiatrist, Dr. H, not already of record, for the period from June 2016. 3. Schedule a VA foot examination. The relevant documents in the record should be made available to the examiner, who should indicate on the examination report that he/she has reviewed the documents in conjunction with the examination. A detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiner should provide the following opinion: Is it at least as likely as not (50 percent or higher degree of probability) that a currently diagnosed bilateral foot disorder, to include pes planus and arthritis, had its onset during a period of active service, including as due to the Veteran's regular course of duties as nurse during service? 4. Then, readjudicate the issue of service connection for a bilateral foot disorder. If any benefit sought on appeal remains denied, the Veteran and representative should be provided a SSOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs