Citation Nr: 1808533 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 09-13 520 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), evaluated as 10 percent disabling prior to February 4, 2009, and 30 percent disabling thereafter, on the basis of substitution. 2. Entitlement to an increased rating for lumbar spine degenerative disc disease and degenerative joint disease, evaluated as 10 percent disabling prior to February 4, 2009, and 20 percent disabling thereafter, on the basis of substitution. 3. Entitlement to service connection for allergic contact dermatitis, to include as due to herbicide exposure, on the basis of substitution. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and the appellant ATTORNEY FOR THE BOARD K. Osegueda, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to June 1969. His awards and decorations included the Purple Heart. The Veteran died in March 2016, and the appellant is the Veteran's surviving spouse. This case initially came before the Board of Veterans' Appeals (Board) on appeal from December 2007 and June 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In a March 2009 rating decision, the RO increased the disability rating for PTSD to 30 percent, effective from February 4, 2009. In addition, the RO increased the disability rating for lumbar spine degenerative disc disease to 20 percent, effective from February 4, 2009. As higher ratings for these disabilities are available and a veteran is presumed to seek the maximum available benefits, the issues remained on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In September 2014, the Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge. The hearing addressed the Veteran's increased rating claims, but it did not address his claim for service connection for allergic contact dermatitis. A transcript of the hearing has been associated with the record. The Board notes that the Veteran withdrew his hearing request for his claim for service connection for allergic contact dermatitis in January 2015. In December 2014, the Board remanded the case for further development. The case was returned to the Board for appellate review. During the pendency of the appeal, the Veteran died, and the appeal was dismissed. In March 2016, the appellant submitted a VA Form 21-534, Application for Dependency and Indemnity Compensation, Death Pension, and Accrued Benefits by a Surviving Spouse or Child. In November 2017, the RO notified the appellant that it had accepted her VA Form 21-534 as a request for substitution and recognized the appellant as a valid substitute claimant. The issue of entitlement to service connection for the allergic contact dermatitis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to February 4, 2009, the Veteran's PTSD manifested in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. His symptoms did not result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Since February 4, 2009, the Veteran's PTSD manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. His symptoms did not result in occupational and social impairment with reduced reliability and productivity. 3. Prior to February 4, 2009, the Veteran did not have forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis. He also did not have incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the previous 12 months. 4. Since February 4, 2009, the Veteran did not have forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. He also did not have incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. CONCLUSIONS OF LAW 1. Prior to February 4, 2009, the criteria for an increased rating greater than 10 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2017). 2. Since February 4, 2009, the criteria for an increased rating greater than 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2017). 3. Prior to February 4, 2009, the criteria for an evaluation in excess of 10 percent for lumbar spine degenerative disc disease and degenerative joint disease have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 4. Since February 4, 2009, the criteria for an evaluation in excess of 20 percent for lumbar spine degenerative disc disease and degenerative joint disease have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the appellant nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their 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 evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). PTSD In this case, the Veteran contended that he was entitled to an increased evaluation for his service-connected PTSD. He was assigned a 10 percent evaluation prior to February 4, 2009, and a 30 percent evaluation from February 4, 2009, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 10 percent is warranted when the psychiatric disorder results in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when the psychiatric disorder results in 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 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 and 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in 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; memory loss for names of close relatives, own occupation, or own name. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The Board notes that the regulations were recently revised to incorporate the Fifth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V) rather than the Fourth Edition (DSM-IV). However, these provisions only apply to cases received by or pending before the AOJ on or after August 4, 2014. The change does not apply to cases certified to the Board prior to that date. In this case, the Veteran's claim was certified to the Board prior to August 4, 2014; therefore, the regulations pertaining to the DSM-IV are for application. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran was not entitled to increased evaluations for his service-connected PTSD. For the period prior to February 4, 2009, the Board concludes that a rating greater than 10 percent is not warranted. For this period, the Veteran was not shown to have occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). In fact, during a September 2007 VA examination, the Veteran reported that he was not receiving any mental health treatment, and he denied having a history of mental health treatment. He had never been in counseling, he was never hospitalized, and he had not taken any psychotropic medications. The examiner noted that the Veteran's social functioning was grossly intact, but he was somewhat isolative and avoidant. The Veteran worked part-time as an electrician, and he owned his own business. He worked 20 to 30 hours per week. The Veteran denied any inappropriate behavior. He acknowledged some short and long-term memory difficulty and attention and concentration problems on examination; however, his math skills were good. The examiner diagnosed the Veteran with chronic, mild to moderate PTSD. She opined that the Veteran's PTSD symptoms were not severe enough to require continuous medication. She also opined that the Veteran's symptoms were not severe enough to interfere with occupational and social functioning. For the period prior to February 4, 2009, the record does not demonstrate that the Veteran's overall disability picture is consistent with a 30 percent rating or higher. To the extent these symptoms may be shown or argued, the Board emphasizes that the Veteran's PTSD has not been shown to be productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. For the period since February 4, 2009, the Board concludes that a rating greater than 30 percent is not warranted. For this period, the Veteran was not shown to have 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; difficulty in establishing and maintaining effective work and social relationships. During a February 2009 VA examination, the Veteran reported ongoing difficulty with intrusive memories, hyperarousal, re-experiencing, irritability, and depression. He indicated that he was receiving VA treatment and that he was taking psychotropic medication to help his memory. The examiner noted that the Veteran's symptoms were both continuous and intermittent, but he had shown increased depression due to problems and pain related to his service-connected low back disability. The Veteran was able to maintain activities of daily living within his physical limitations, including personal hygiene. He denied any inappropriate behavior. The examiner noted that the Veteran's social functioning was grossly intact for basic skills, but he was somewhat isolative and avoidant. The Veteran was only working six to ten hours per week; however, he indicated that he had increased difficulty working due to his back problems. He continued to endorse some short-term memory and attention and concentration difficulty; however, the examiner noted that the Veteran's long-term memory appeared better. He had good judgment, and his math skills were good. The examiner diagnosed the Veteran with chronic, mild to moderate PTSD. She noted that the Veteran's PTSD required continuous medication. She opined that there was occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms, but the Veteran was generally satisfactorily functioning with regard to routine behavior, self-care, and normal conversation. During a June 2012 VA examination, the Veteran stated that he had been married to his wife for 42 years. He described their relationship as very good, and he indicated that they went out to dinner approximately once per week. He noted that he could be irritable and argumentative with people, including his wife. He related that he and his wife socialized occasionally with neighbors and their grown children. He also reported that he played poker with friends. He indicated that he had some lifelong friends, but he generally had difficulty socializing with people outside of that circle and in making new friends. He estimated that he had six or seven friends in his entire life that he had trusted. He noted that he had a good relationship with his adult children and grandchildren. As to occupational impairment, the Veteran reported that he had worked as an electrician for 42 years. He continued to work in the field, but he was unable to physically work full-time. He related that he and his wife owned their own company for 26 years and that it was a positive arrangement because he could work mostly independently. He indicated that he could become easily aggravated with clients, but that his wife typically interfaced with them. The Veteran endorsed the following symptoms: restricted range of affect; difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. The examiner noted that the Veteran had a depressed mood; suspiciousness; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner further stated that the Veteran experienced impairment with regard to interpersonal and occupational functioning on a chronically mild and episodically moderate level. During an August 2015 VA examination, the Veteran reported that he was married to his wife for 45 years and that he had a close relationship with her. He indicated that he and his wife had verbal arguments in the past, but they were never physically violent toward one another. He stated that his anger and temper had softened over the years and that they were no longer problematic. He related that he became irritable at times, but he no longer lost his temper. He stated that his marriage improved when he quit drinking approximately one year ago. He denied feelings of disengagement from people, and he related that he was close to his family and friends. He had three children and three grandchildren and noted that they lived locally and that he maintained frequent contact with them. He reported that he had some friends that he got together with for Friday night poker occasionally. He indicated that he was a member of a local community center where he swam and worked out. He stated that he went to dinner, shopped at garage sales and antique stores, and gambled at the casino with his wife. As to employment, the Veteran reported that he serviced and provided estimates on generators. He stated that he reduced his work hours over the years due to shoulder and back pain and that he worked between eight to ten hours per week. He indicated that he had years of experience in his field, so he did not have any problems with work performance. He reported that he occasionally misplaced a part, but he could eventually track it down. He denied making any serious errors on the job. He indicated that he would probably be working full-time, or at least work more hours, if he did not have chronic pain issues. When he was free, he worked on various house remodeling projects and split logs for the fireplace. The August 2015 VA examiner noted that the Veteran had a depressed mood, anxiety, and impairment of short and long-term memory. However, the examiner also indicated that the Veteran had unspecified neurocognitive impairment. She noted that the Veteran reported an onset of memory problems six or seven years ago with a steady worsening over time, which suggested an organic etiology with a degenerative course. She related that the specific etiology was unknown, but risk factors included a history of chronic obstructive pulmonary disease (COPD) and genetic loading for early onest dementia. The Veteran reported that he sometimes he fell asleep immediately and other times he had delayed onset of sleep. He related that his sleep was usually continuous, but sometimes he woke up around 3 a.m. and watched television on the couch until he fell back asleep. He denied having any nightmares. He reported that he slept five to six hours per night. He described mild hypervigilance, and he endorsed an exaggerated startle response to large bangs, such as car backfires. He indicated that his startle reflex had improved over time though. He reported experiencing depression and anxiety primarily related to financial issues, pain, and health. He denied any current or recent suicidal thoughts, ideation, intent, or planning. He also denied having any hallucinations, psychotic symptoms, mania, obsessions, compulsions, or ritualistic behavior. The examiner noted that the Veteran was appropriately groomed and attired. He presented with euthymic mood and bright affect. He exhibited some difficulty with recalling and dating events from his history, but he did not demonstrate any psychomotor abnormalities. His speech was normal with the exception of occasional word-finding inefficiencies. His process of thought was organized, linear, and goal-directed, and his level of insight and judgment appeared to be fair to good. The examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversations. To the extent any of the symptoms of a 50 percent rating may be shown or argued, the Board again emphasizes that the Veteran's PTSD has not been shown to be productive of occupational and social impairment with reduced reliability and productivity for the period since February 4, 2009. As discussed above, the Veteran's anxiety, irritability, and depression appear to be intermittent during times of stress and exacerbations of pain related to his various musculoskeletal disabilities, rather than persistent problems. There is no also indication that he has had any of the other symptoms of the 70 or 100 percent criteria, such as obsessional rituals; illogical, obscure, or irrelevant speech; neglect of his personal appearance and hygiene; homicidal ideation; or disorientation to time or place. The Board acknowledges that the Veteran had been assigned GAF scores ranging from 54 to 56. A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning. See 38 C.F.R. §§ 4.125, 4.130, DSM-IV. GAF scores assigned are but one factor for consideration in a rating, but the Board does note that the Veteran's GAF scores in this case do not suggest that the Veteran's symptomatology and impairment warrants an evaluation in excess of 30 percent. Nevertheless, while considering the GAF score of record as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the lay statements, treatment records, and examination reports to be the most probative evidence of the Veteran's psychological symptomatology. After considering the evidence of record, the Board finds that the Veteran did not demonstrate a level of impairment consistent with the criteria of increased ratings of 30 percent prior to February 4, 2009, or 50 percent thereafter, nor have the Veteran's symptoms caused occupational and social functioning in most of the areas or total occupational and social functioning referenced by the 70 and 100 percent evaluation criteria. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher ratings of 30 and 50 percent have not been met or approximated. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Lumbar Spine Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. In this case, the Veteran contended that he was entitled to an increased evaluation for his service-connected lumbar spine degenerative disc disease and degenerative joint disease. He was a 10 percent evaluation prior to February 4, 2009, and a 20 percent evaluation from February 4, 2009, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 indicates that degenerative arthritis of the spine should be evaluated under the General Rating Formula for Diseases and Injuries to the Spine (General Rating Formula). Under the General Rating Formula, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diagnostic Codes 5235-5243. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the thoracolumbar spine is 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. See 38 C.F.R. § 4.71a, General Rating Formula, Note (2) and Plate V. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Id., Note (2). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that increased ratings for the periods prior to February 4, 2009 and thereafter are not warranted for the Veteran's lumbar spine disability. For the period prior to February 4, 2009, the Board concludes that a rating greater than 10 percent is not warranted. For this period, the Veteran was not shown to have forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees based on the range of motion measurements of record. In fact, a September 2007 VA examination revealed forward flexion to 89 degrees, lateral bending to the left to 28 degrees, lateral bending to the right to 28 degrees, and rotation to the left and right to 30 degrees. He had pain at the end of the motion with forward flexion and lateral bending to the left. He had no pain with lateral bending to the right and rotation to the left and right. There was no additional limitation of motion, fatigue, impaired endurance, or weakened movement following repetitive motion testing. For the period since February 4, 2009, the Board concludes that a rating greater than 20 percent is not warranted. For this period, the Veteran was not shown to have forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. In fact, a February 2009 VA examination revealed forward flexion from 0 to 55 degrees; extension from 0 to 20 degrees; left lateral flexion to 30 degrees; right lateral flexion to 20 degrees; and bilateral lateral rotation from 0 to 30 degrees. There was objective evidence of increased pain at the extremes of movement on range of motion testing. The examiner noted that there was no change in active or passive range of motion during repetitive use testing, and no additional limitation of motion due to painful motion, weakness, impaired endurance, incoordination, or instability. Additionally, during an October 2012 VA examination, the Veteran demonstrated forward flexion to 55 degrees with pain at 50 degrees; extension to25 degrees with pain at 20 degrees; left lateral flexion to 30 degrees or greater with pain at 20 degrees; right lateral flexion to 20 degrees with pain at 20 degrees; left lateral rotation to 30 degrees or greater with no objective evidence of painful motion; and right lateral rotation to 30 degrees or greater with no objective evidence of painful motion. Again, there were no additional limitations after three repetitions of range of motion testing. Moreover, a June 2015 VA examination reported forward flexion from 0 to 75 degrees; extension from 0 to 20 degrees; right lateral flexion from 0 to 20 degrees; left lateral flexion from 0 to 20 degrees; right lateral rotation from 0 to 30 degrees; and left lateral rotation from 0 to 30 degrees. There was no pain noted on examination and no pain with weight bearing. There was also no additional limitation of motion after repetitive motion testing. In addition, throughout the entire appeal, the Veteran has not been shown to have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. In this regard, the September 2007 VA examiner specifically reported that the Veteran had no spams or tenderness of the scalene muscles, and the February 2009 VA examiner indicated that the Veteran had no scoliosis, spasm, or tenderness of the thoracolumbar spine on examination. The October 2012 and June 2015 VA examiners also reported that the Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Moreover, there is no indication that the Veteran has had incapacitating episodes for a rating under the intervertebral disc syndrome rating criteria noted above. In this regard, the October 2012 and June 2015 VA examiners reported that the Veteran did not have intervertebral disc syndrome. Further, the Board observes that there are no treatment records associated with the claims file indicating that the Veteran was prescribed bed rest by any physician for his lumbar spine disability. The Veteran also specifically denied having a history of incapacitating episodes of back pain that required physician-ordered bedrest during the last year during the September 2007 and February 2009 VA examinations. As such, the Veteran has not been shown to have met the criteria for an increased evaluation under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board further notes that the Veteran was already service-connected for radiculopathy of the left and right lower extremity associated with his lumbar spine disability. Moreover, there is no evidence of any other neurological disability associated with his lumbar spine disability. Indeed, the October 2012 and June 2015 VA examiners stated that there were no other neurologic abnormalities or findings related to the disability, such as bowel or bladder problems or pathologic reflexes. Therefore, the Board finds that a separate disability rating is not warranted because the evidence does not demonstrate that the Veteran suffers from a separate neurological disability distinct from his already service-connected lumbar spine disability and radiculopathy. See Bierman v. Brown, 6 Vet. App. 125, at 129-32 (1994). The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, increased evaluations for the Veteran's lumbar spine disability are not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms were supported by pathology consistent with the assigned 10 and 20 percent ratings, and no higher. In this regard, the Board observes that the Veteran complained of pain on numerous occasions. However, the effect of the pain in the Veteran's lumbar spine was contemplated in the assigned evaluations. The Veteran's complaints did not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. During the September 2007 VA examination, the Veteran had pain at the end of the motion with forward flexion and lateral bending to the left. He had no pain with lateral bending to the right and rotation to the left and right. There was no additional limitation of motion, fatigue, impaired endurance, or weakened movement following repetitive motion testing. During the February 2009 VA examination, there was objective evidence of increased pain at the extremes of movement on range of motion testing. The examiner noted that there was no change in active or passive range of motion during repetitive use testing, and no additional limitation of motion due to painful motion, weakness, impaired endurance, incoordination, or instability. During the October 2012 VA examination, the Veteran demonstrated pain on range of motion testing; however, again, there were no additional limitations after three repetitions of range of motion testing. Moreover, during the June 2015 VA examination, the examiner noted that the Veteran had no pain on examination and no pain with weight bearing. There was also no additional limitation of motion after repetitive motion testing. Therefore, the Board finds that the effect of the pain in the Veteran's back is contemplated in the assigned 10 and 20 percent evaluations. The Veteran's complaints did not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant increased evaluations throughout the appeal. Based on the foregoing, the Board finds that the weight of the evidence is against increased ratings for the lumbar spine disability. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied in this regard. Gilbert, 1 Vet. App. 49 (1990). Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER An increased rating in excess of 10 percent for PTSD prior to February 4, 2009, on the basis of substitution is denied. An increased rating in excess of 30 percent for PTSD from February 4, 2009, on the basis of substitution is denied. An increased rating in excess of 10 percent for lumbar spine degenerative disc disease and degenerative joint disease prior to February 4, 2009, on the basis of substitution is denied. An increased rating in excess of 20 percent for lumbar spine degenerative disc disease and degenerative joint disease from February 4, 2009, on the basis of substitution is denied. REMAND The Board notes that the Veteran was not afforded a VA examination in connection with claim for service connection for allergic rhinitis. He served in the Republic of Vietnam during the Vietnam era; therefore, he is presumed to have been exposed to herbicides during his military service. His post-service treatment records also show that he was seen for a skin condition. Although the Veteran may not have had a disorder on the list of diseases that VA has associated with Agent Orange exposure, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. §§ 3.303(d), 3.309(e); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). Therefore, the Board finds that a medical opinion is needed. Moreover, as noted in the directive below, it appears that there may be outstanding records. Thus, on remand, the AOJ should attempt to obtain such records. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the appellant provide the names and addresses of any and all health care providers who have provided treatment for the Veteran's allergic contact dermatitis or any other skin disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. A specific request should be made for any outstanding private treatment records from allergy testing at the University of Colorado in July 1988. 2. After completing the foregoing development, the AOJ should refer the claims file to a suitably qualified VA examiner for a medical opinion to address the nature and etiology of the Veteran's allergic contact dermatitis. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, the Veteran's statements, and the appellant's statements. The Veteran contended that his allergic contact dermatitis was caused by exposure to Agent Orange during service. He claimed that he was allergic to epoxy and that he developed the allergy due to the epoxy used in Agent Orange defoliants. It should be noted that the appellant is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's allergic contact dermatitis or any other skin disorder that was causally or etiologically related to his military service, to include any presumed herbicide exposure therein. In forming this opinion, the examiner should specifically address the Veteran's contention that he developed an epoxy allergy during service from the epoxy used in Agent Orange defoliants. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should review the medical opinion to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claim should be readjudicated. If the benefit sought is not granted, the appellant and her representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017). Department of Veterans Affairs