Citation Nr: 18146874 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 18-25 058 DATE: November 1, 2018 ORDER Reconsideration of a previously denied claim of entitlement to service connection for schizophrenia is granted. Entitlement to service connection for schizophrenia is granted. An effective date earlier than February 12, 2016, for the award of service connection for left knee patellofemoral pain syndrome is denied. REMANDED The claim of entitlement to service connection for sleep apnea is remanded. The claim of entitlement to an initial disability rating higher than 10 percent for left knee patellofemoral pain syndrome is remanded. FINDINGS OF FACT 1. In a July 2015 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) confirmed and continued a prior August 2014 denial of service connection for schizophrenia. Although notified of the continued denial of this claim in a letter also dated in July 2015, the Veteran did not initiate an appeal; however, new and material evidence pertinent to the claim was received within one year. 2. Although schizophrenia was not diagnosed in service, he was seen for mental health problems then assessed as adjustment disorder, and the competent, probative opinion evidence on the question of whether current schizophrenia had its onset in service is in relative equipoise. 3. A formal claim of entitlement to service connection for left knee disability was filed on February 12, 2016; there is no evidence or allegation of any pending (unadjudicated) formal or informal claim for service connection for left knee disability prior to that date. CONCLUSIONS OF LAW 1. As evidence received since the July 2015 denial of service connection claim for schizophrenia includes new and material evidence received prior to the expiration of the appeal period, the criteria for reconsideration of that claim are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. Resolving all reasonable doubt in the Veteran’s favor, the criteria for service connection for schizophrenia are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The claim for an effective date earlier than February 12, 2016, for the award of service connection for left knee patellofemoral pain syndrome is without legal merit. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2008 to September 2012. This appeal to the Board of Veterans Appeals (Board) arose from July 2015 and March 2016 rating decisions. Initially, in an August 2014 rating decision, the RO, inter alia, denied the claim for service connection for schizophrenia. In June 2015, the RO reconsidered the claim, but confirmed and continue the prior denial. In the March 2016 rating decision, the RO denied service connection for sleep apnea, again confirmed the prior denial of service connection for schizophrenia, and granted service connection for left knee patellofemoral pain syndrome, assigning a noncompensable disability rating, effective February 12, 2016. The Veteran disagreed with the denial of his schizophrenia and sleep apnea claims, as well as with the effective date and assigned disability rating for the left knee disability, and thereafter perfected an appeal as to these matters. Subsequently, in a November 2017 rating decision, the RO assigned a 10 percent disability rating for the Veteran’s left knee disability, still effective February 12, 2016. As a higher rating is available for the left knee disability, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Additionally, as the Veteran disagreed with the initial rating assigned following the award of service connection for the left knee disability, the Board has characterized the claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). For reasons made clear below, the Board has characterized the appeal with respect to the Veteran’s schizophrenia claim as encompassing both the matters of reconsideration of the claim—and, given the favorable disposition of that matter—service connection for schizophrenia and the matter of service connection on the merits. As explained below, the claim adjudicated as a request to reopen is more appropriately characterized as an appeal for reconsideration of the claim, consistent with the provisions of 38 C.F.R. § 3.156(b). Moreover, given the favorable disposition of the reconsideration issue, as discussed below, the appeal also has been expanded to include the underlying claim for service connection. 1. Reconsideration The Veteran’s claim for service connection for schizophrenia was initially denied by the RO in an August 2014 rating decision. The RO confirmed and continued the prior denial in a July 2015 rating decision. Pertinent evidence then of record included the Veteran’s service treatment and personnel records, VA treatment records, August 2014 and July 2015 VA examination reports, and lay statements. The RO continued to deny the claim based on a lack of evidence that the condition was incurred during or was caused by the Veteran’s active service. Although notified of the July 2015 denial in a letter dated that same month, the Veteran did not initiate an appeal. See 38 C.F.R. § 20.200. Typically, that fact would Typically, this fact would render the decision final as to the evidence then of record, and not subject to revision on the same factual basis. See 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Under such circumstances, VA could only reopen and review such claims if new and material evidence is submitted by or on behalf of the Veteran. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). However, if new and material evidence was received during an appellate period following an RO decision (one year for a rating decision and 60 days for a statement of the case) or prior to an appellate (Board) decision (if an appeal was timely filed), the new and material evidence will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009). Thus, under 38 C.F.R. § 3.156(b), “VA must evaluate submissions received during the relevant [appeal] period and determine whether they contain new evidence relevant to a pending claim, whether or not the relevant submission might otherwise support a new claim.” Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). “[N]ew and material evidence” under 38 C.F.R. § 3.156(b) has the same meaning as “new and material evidence” as defined in 38 C.F.R. § 3.156(a). See Young, 22 Vet. App. at 468. “New” evidence is evidence not previously submitted to agency decision makers and “material” evidence is 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 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). Here, within one year of the July 2015 rating decision, additional evidence was associated with the claims file, to include an October 2014 addendum treatment report wherein the Veteran’s treating VA psychiatrist opined that the Veteran’s schizophrenia symptoms began while on active duty in the U.S. Navy, and has persisted since that time. Additionally, in February 2016, within one year of issuance of the July 2015 rating decision that confirmed and continued the prior denial of the service connection claim for schizophrenia the Veteran submitted an additional claim for psychiatric disability. Moreover, additional VA treatment records, including a record of emergency room treatment for the Veteran’s schizophrenia and records and evaluation reports relevant to the schizophrenia claim, were associated with the claims file. These records provide evidence of the Veteran’s continuing schizophrenia diagnosis and his need for ongoing treatment for the disability. The records additionally note his report of having disturbing memories associated with the disability. The Board finds that the above-described It is “new” in that it was not before the RO at the time of the August 2014 or July 2015 denials and is not duplicative or cumulative of the evidence previously of record. Additionally, this evidence is “material” in that it is relevant to the claim on appeal, and relates to unestablished facts necessary to substantiate the claim for service connection at issue; namely, whether there is a link between the Veteran’s current schizophrenia disability and his active service. When considered in light of the evidence previously of record—the prior statements from the Veteran’s VA psychiatrist’s noting that his schizophrenia likely began while he was on active duty and has persisted since that time—the evidence also provides a reasonable possibility of substantiating the claim. Thus, as new and material evidence within the meaning of 38 C.F.R. § 3.156(a) was received within one year of the August 2014 denial, reconsideration of the claim is warranted. See 38 C.F.R. § 3.156(b). 2. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in or aggravated by service. See 38 C.F.R. § 3.303(d). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The determination as to whether the elements of a claim are met is based on an analysis of all the evidence of record and evaluation of its competency, credibility and probative value. See Buchanan v. Nicholson, 451 F.3d 1331(Fed. Cir. 2006) Baldwin v. West, 13 Vet. App. 1, 8 (1999). In adjudicating a claim for VA benefits, 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 the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Veteran essentially asserts that he developed schizophrenia during his active duty service. Turning to the requirements for service connection, as for the matter of a current disability, the Veteran’s VA treatment records document multiple instances where he was diagnosed with paranoid type schizophrenia, including as early as in October 2013. Schizophrenia was also diagnosed on August 2014 VA examination. As for the in-service injury or disease requirement, the Veteran’s STRs document that the Veteran sought mental health treatment in June 2009. A June 2009 mental health treatment report noted that the Veteran began having problems about one month prior when his sister died at the age of 23. The report noted that he was struggling to adapt. The Veteran reported to the clinician that before his sister died, “things were always bad, but ‘not like this.’” At the time of evaluation, he presented with suicide ideation, depression, and bereavement. The clinician diagnosed adjustment disorder with depressed mood. The plan was for the Veteran to receive weekly counseling sessions. While the Veteran remained on active duty, ongoing treatment records note a continuing diagnosis of adjustment disorder. In a report of medical history associated with his August 2012 separation examination report, he reported having had nervous trouble, frequent trouble sleeping, and depression or excessive worry. Thus, the remaining question is whether there exists a medical nexus, or link, between current schizophrenia and service, to include problems noted therein. In support of his service connection claim, the Veteran submitted a September 2017 mental disorders disability benefits questionnaire (DBQ) completed by a private psychologist, noting a diagnosis of continuous schizophrenia. The psychologist provided a supplemental letter dated in April 2018. In the, the psychologist provided the opinion that based on interview of the Veteran and review of his claims file, his schizophrenia more likely than not began during his active service, and continued uninterrupted to the present. In providing this opinion, the psychologist noted that evidence existed showing that the Veteran was experiencing prodromal mental health symptoms upon his exit interview from service, and during hospitalization in 2013. In addition to this probative evidence, review of the Veteran’s VA treatment records reveals that his treating VA psychiatrist provided significant opinions in support of his claims. In a May 2014 mental health evaluation, the VA psychiatrist noted that he had reviewed the Veteran’s psychiatric history with him, and that while on active duty, prior to using Spice or any other substance abuse, the Veteran was treated by a psychologist for depression, anxiety, and “other stuff.” He noted that it was his opinion that the Veteran suffered with chronic paranoid delusions, and when acutely ill, auditory hallucinations with ideas of reference, because he had been correctly diagnosed with and treated appropriately for chronic paranoid schizophrenia; and his symptoms began while on active duty in the U.S. Navy. Additionally, in an October 2014 addendum report, the psychiatrist noted that the Veteran’s psychotic and mood symptoms clearly began while he was on active duty in the U.S. Navy. The psychiatrist asserted that is was opinion that that while the Veteran’s state of mind was no doubt influenced by substance abuse as that time, he clearly suffered with paranoid schizophrenia and the prodrome of that illness very likely began at his last command, and was misdiagnosed. The Board finds the opinion provided by the private psychologist in April 2018, and the May 2014 and October 2014 opinions provided by the Veteran’s treating VA psychiatrist, to be of significant probative value. Both clinicians had reviewed the Veteran’s STRs and were familiar with his mental health treatment history. Both clinicians noted that medical evidence supported a finding that the Veteran’s symptoms began during his active service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Considering the opinions from the private psychologist and the treating VA psychiatrist, the Board finds that there is sufficient probative evidence to warrant a finding that the Veteran’s current schizophrenia at least as likely as not began during his active service. The Board also notes, however, that the record also includes two negative opinions provided by VA examiners. In an August 2014 VA examination report, a VA psychologist opined that there was no evidence that the Veteran’s schizophrenia was incurred in the military. The examiner also referenced a possible genetic component to the Veteran’s schizophrenia, but then concluded that his first psychotic break occurred after he separated from active service and was precipitated by drug use, the breakup of his marriage, and being homeless. The examiner also indicated that the Veteran’s military records reflected a good level of functioning, and that if he had been ill with schizophrenia it is very unlikely that it would have gone unidentified by a mental health professional at that time. In a July 2015 VA examination report, another VA psychologist again noted that the Veteran’s first psychotic break was in June 2013 and indicated that the STRs reflects symptoms in 2009 consistent with adjustment disorder, depression, and bereavement. The examiner opined that there was no indication of chronic progressive problems that would have been consistent with prodromal schizophrenia during service. Thus, the examiner opined that it was less likely than not that the Veteran’s schizophrenia began during service, or was caused by the adjustment disorder that occurred in June 2009. Based on this record, while the Board has determined that there is sufficient probative evidence to find that the Veteran’s schizophrenia symptoms first became manifest during service, the Board acknowledges that there is likewise probative evidence indicating that the disability may not have become manifest until after his separation from service. Nonetheless, the Board finds that the medical opinions weighing for and against the claim—all rendered by appropriate mental health professionals based on consideration of the same evidence—are relatively evenly balanced, or in relative equipoise; thus, warranting application of the benefit-of-the-doubt doctrine. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 3.102; see also 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 53-56. Given the facts noted above, and resolving any reasonable doubt in the Veteran’s favor on the medical nexus element of the claim, the Board concludes that the criteria for service connection for schizophrenia are met. 3. Earlier Effective Date Generally, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments are effective for claims and appeals filed on or after March 24, 2015. Thus, the amendments are applicable to the Veteran’s appeal. Prior to March 25, 2015, a claim could be either a formal or informal written communication “requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit.” See 38 C.F.R. § 3.1 (p) (2016); but see 38 C.F.R. § 3.1 (p) (2016) (now providing that a “claim” must be submitted on an application form prescribed by the Secretary). It has been held that an intent to apply for benefits is an essential element of any claim, whether formal or informal, and, further, the intent must be communicated in writing. It logically follows that where there can be found no intent to apply for VA benefits, a claim of entitlement to such benefits has not been reasonably raised. Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006). See also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations require a claimant to have intent to file a claim for VA benefits). In this case, while the Veteran generally contends that an effective date earlier than February 12, 2016, is warranted for the award of service connection for the left knee patellofemoral pain syndrome, he has made no specific argument as to when the appropriate effective date for the disability should be or as to why an earlier effective is warranted. Considering the record in light of the noted legal authority, the Board finds that no earlier effective date is assignable. Here, the evidence clearly shows that the Veteran first filed a claim for service connection for left knee disability, on VA Form 21-526EZ, that was received on February 12, 2016. Significantly, there is no evidence whatsoever of any unadjudicated formal or informal claim for service connection for left knee disability prior to the February 2016 claim—even before the enactment of 79 Fed. Reg. 57660. Thus, there is no reasonable doubt to be resolved in the Veteran’s favor on this point. While the Board acknowledges that the Veteran submitted prior claims for service connection, including for schizophrenia, in August 2014 and in July 2015, there is no specific indication that he intended to file a claim for service connection for any left knee disability prior to the February 2016 claim. Additionally, while review of the Veteran’s VA treatment records indicates that he began complaining of left knee pain in October 2014, the mere presence of the disability cannot serve as a basis for a service connection claim, even if such disability was causally connected to active service. Cf. Lalonde v. West, 12 Vet. App. 377, 382-383 (1999) (holding that “the effective date of an award of service connection is not based on the date of the earliest medical evidence demonstrating a causal connection, but on the date that the application upon which service connection was eventually awarded was filed with VA.”). Even prior to the enactment of 79 Fed. Reg. 57660, there is no submission from the Veteran showing his intent to apply for VA benefits for the left knee disability. See Criswell, MacPhee, supra. Notably, the legal authority governing effective dates is clear and specific, and the Board is bound by such authority. Although the Board is required to “render a decision which grants every benefit that can be supported in law,” under these circumstances, there is no legal basis to grant the appeal for an earlier effective date for the award of service connection for the left knee disability. See 38 C.F.R. § 3.103(a). Accordingly, the Veteran’s appeal as to this claim must be denied for lack of legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). REASONS FOR REMAND The Board’s review of the claims file reveals that further AOJ action on the remaining claims on appeal is warranted. With respect to his sleep apnea claim, the Veteran’s VA treatment records reflect a diagnosis of sleep apnea and treatment using a CPAP machine. Additionally, his STRs indicate that he suffered from sleep disturbance and complained of getting tired for no reason during his active service, including in June 2009 and October 2009. Moreover, during VA treatment in February 2016, the Veteran indicated his belief that his sleep apnea may be the result of other conditions. The Board notes that VA is required to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to decide the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Thus, as the evidence indicates that the Veteran suffers from sleep apnea, and there is evidence indicating a possible link between his sleep apnea and his active service or service-connected disability, but no reasonably definitive etiology opinion of record, the Board finds that the McLendon requirements are met. Therefore, a remand of this claim is warranted to afford the Veteran a VA examination to obtain etiology opinions for his sleep apnea. Concerning the Veteran’s claim for a higher rating for service-connected left knee disability, the Board observes that a precedential opinion of the United States Court of Appeals for Veterans Claims (Court) is directly applicable to the claim. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA musculoskeletal examinations include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding establishes requirements that must be met for an adequate VA musculoskeletal examination. The Board further notes that the Veteran reported during VA examination in March 2016, that he suffers from flare-ups of the left knee joint disability. Another precedential Court opinion, Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), further requires that where, as here, a veteran reports having flare-ups of joint disability, the examination reports must describe the frequency, duration, characteristics, severity, and functional loss due to flare-ups. No such descriptions have been provided for the Veteran’s left knee disability. The March 2016 VA examiner indicated that she could not provide an opinion as to whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups without mere speculation, The Board notes that the Court in Sharp addressed the adequacy of “mere speculation” opinions, and explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering an opinion consistent with DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, it is anticipated that VA “examiners will offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of veterans.” Id. at 35. Accordingly, remand of the higher rating claim is warranted for a new VA examination of the Veteran’s left knee to obtain clinical findings that are properly responsive to the considerations addressed in Correia and Sharp. See 38 C.F.R. § 4.2. Prior to arranging for new VA examinations, to ensure that all due process requirements are met, and the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file currently includes VA outpatient treatment reports dated through April 2017. Accordingly, the AOJ should obtain all outstanding records of VA evaluation and/or treatment of the Veteran dated since April 2017. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the service connection and increased rating claims on appeal, explaining that he has a full one-year period for response. See 38 U.S.C. § 5103(b)(1); but see also 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims on appeal. Adjudication of the higher rating claim should include consideration of whether staged rating of the disability—assignment of different ratings for distinct periods of time, based on the facts found—is appropriate. These matters are hereby REMANDED for the following action: 1. Obtain complete copies of all outstanding records of VA evaluation and/or treatment of the Veteran, dated since April 2017. Follow the procedures set forth in 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his attorney a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to one or more claim(s) on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claims within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received are associated with the claims file, arrange for the Veteran to undergo a VA examination for sleep apnea by an appropriate physician. The contents of the entire electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the physician prior to the completion of his or her report), and all clinical findings should be reported in detail. With respect to diagnosed sleep apnea, the examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability: (a) had its onset in service or was otherwise related to an in-service injury, disease, or event, to include the noted instances of sleep disturbance and of feeling tired for no reason during service; or, if not, (b) was caused, OR is or has been aggravated (worsened beyond the natural progression) by now service-connected schizophrenia. Id aggravation is found, the physician should attempt to quantify the extent of additional disability resulting from aggravation—to include by identifying, to the extent possible, the baseline level of disability prior to aggravation. In addressing the above, the examiner must consider and discuss all medical and other objective evidence of record, as well as all lay assertions. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA knee examination by an appropriate medical professional. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should conduct range of motion testing (expressed in degrees) of the left knee on both active motion and passive motion, and in weight bearing and non-weight bearing (as appropriate). The examiner should also conduct range of motion testing of the right knee, for comparison purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly so state, and explain why. The examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner should indicate the point at which pain begins. Also, the examiner should describe the frequency, duration, characteristics, severity, and functional loss during flare-ups of left knee disability. If the examination is not conducted during a flare-up, based on examination results and the Veteran’s documented history and assertions, the examiner should also indicate whether, and to what extent, the Veteran experiences likely functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. If it is not feasible for the examiner to make the above determinations without resorting to speculation, he or she must provide an explanation for why this is so. The examiner is advised that the inability to provide an opinion without resorting to speculation must be based the limitation of knowledge in the medical community at large and not a limitation-whether based on lack of expertise, insufficient information, or unprocured testing-of the individual examiner. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 6. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App.268, 271 (1998).. 7. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claims on appeal considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority (to include, with respect to the higher rating claim, consideration of whether staged rating of the disability is appropriate). JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael Wilson, Counsel