Citation Nr: 20021375 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 16-37 899 DATE: March 25, 2020 ORDER Service connection for an acquired psychiatric disorder, to include of anxiety disorder, depressive disorder, adjustment disorder, and posttraumatic stress disorder (PTSD), is granted. Service connection for a respiratory/pulmonary disorder is denied. The claim of entitlement to a total disability rating based on individual unemployability (TDIU) is dismissed. A compensable disability rating for eczematous dermatitis is denied. A 10 percent disability rating for gastroesophageal reflux disease (GERD) is granted. REMANDED The claim of entitlement to service connection for allergic rhinitis is remanded. FINDINGS OF FACT 1. Resolving all doubt in his favor, the Veteran has current diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and PTSD which have been related to his service on a direct basis. 2. There is no evidence of respiratory/pulmonary complaints in service and no medical evidence of current complaints. 3. Prior to the promulgation of a decision in the appeal, in February 2020 correspondence, the Veteran withdrew his appeal concerning the issue regarding entitlement to a TDIU. 4. For the entire appeal period, the Veteran’s eczematous dermatitis covers less than 5 percent of his entire body and less than 5 percent of exposed areas and, while the Veteran regularly uses of a topical corticosteroid to treat his skin disability, this is not shown to be systemic therapy. 5. For the entire appeal period, the Veteran’s GERD has been manifested by pyrosis (heartburn), which is relieved by medication, as well as reflux, which accounts for acid coming into the mouth, similar to regurgitation, and sleep disturbance (caused by esophageal reflux four or more recurrences per year lasting less than one day). There is no evidence of recurrent epigastric distress with dysphagia, accompanied by substernal or arm or shoulder pain, or showing of symptoms productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a respiratory/pulmonary disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The claim of entitlement to a TDIU is dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 4. The criteria for a compensable disability rating for eczematous dermatitis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7806. 5. The criteria for a 10 percent disability rating for GERD have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.114, DCs 7399-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2009 to June 2009 and January 2012 to September 2012. This case comes on appeal to the Board of Veterans’ Appeals (Board) from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. Notably, the RO adjudicated the Veteran’s acquired psychiatric disorder claim as separate claims for service connection for adjustment disorder and PTSD. In Clemons v. West, 206 F.3d 1401, 1403 (Fed. Cir. 2000), the United States Court of Appeals for the Federal Circuit clarified how the Board should analyze claims for PTSD and other acquired psychiatric disorders. As emphasized in Clemons, though a veteran may only seek service connection for PTSD, the veteran’s claim “cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed.” Id. Therefore, the Board will address whether service connection is warranted for an acquired psychiatric disorder, however diagnosed. The issue has been recharacterized accordingly as noted on the title page. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Service connection for an acquired psychiatric disorder, to include adjustment disorder, PTSD, and major depressive disorder is granted. The Veteran contends that service connection is warranted for an acquired psychiatric disorder due to his military service. Specifically, in a July 2014 statement, the Veteran wrote that, while serving in Afghanistan, he was under constant threat of IED explosions, mortars, bombs, grenades, and snipers. Also, in an August 2015 statement, the Veteran wrote that he was the team lead and worked with both the morgue and mortuary to dispose of dead soldiers. Significantly, the Veteran contends that he has experienced continued psychiatric problems since his military service. The Veteran’s service treatment records are negative for psychiatric problems. Post-service VA treatment records show psychiatric problems as early as July 2014 when the Veteran was diagnosed with general anxiety disorder as well as major depressive disorder. In connection with this claim, he was afforded a VA psychiatric examination in February 2015. Significantly, the examiner diagnosed adjustment disorder with anxiety and opined that it was less likely as not that the Veteran’s claimed psychiatric disorder was incurred in or caused by the Veteran’s military service. As rationale for this opinion, the examiner wrote that there was no evidence of psychiatric complaints, findings, or treatment either prior, during, or within one year of the Veteran’s military service. The Veteran first sought psychiatric care in 2014, two years after his service, following the Veteran’s divorce, being accused of domestic violence, and being placed under electronic surveillance due to these accusations. Significantly, the February 2015 VA examiner also wrote that the Veteran did not meet the DSM-V stressor criteria for PTSD. Significantly, the Veteran did not fulfill the symptoms criteria for persistent re-experiencing of the traumatic event or the symptoms criteria for persistent hyper arousal. Neither did the trauma exposure cause impairment in social, occupational, or other areas of functioning. There was no change in functional status or in quality of life due to the military service or trauma exposure. The Veteran was living a very successful, social, and academic life until his wife accused him of domestic violence in July 2014. Therefore, a diagnosis of PTSD could not be made. The Veteran was afforded a second VA psychiatric examination in October 2015 at which time the examiner noted a diagnosis of unspecified anxiety disorder. No etiology opinion was provided at that time. In connection with this claim, the Veteran submitted an August 2018 private psychiatric evaluation from Dr. A.L.G. Significantly, Dr. A.L.G. diagnosed PTSD and major depressive disorder and opined that such were related to his military service. As rationale for this opinion, Dr. A.L.G. noted that the Veteran’s psychiatric symptoms dated back to at least 2012, when his symptoms of PTSD as well as mood regulation problems began to negatively affect his ability to function appropriately and effectively and initially used alcohol as a mechanism to self-medicate before pursuing mental health services in 2014. Also of record are VA treatment records dated through August 2019 and statements from the Veteran regarding in-service stressors and current psychiatric problems. As above, the Veteran contends that he has experienced psychiatric problems since his military service and a July 2014 VA treatment report shows diagnoses general anxiety disorder as well as major depressive disorder. Upon review of the above, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for an acquired psychiatric disorder is warranted. As an initial matter, the Board finds that the Veteran has current diagnoses of several acquired psychiatric disorders including general anxiety disorder, major depressive disorder, adjustment disorder, and potentially PTSD. While there is disagreement as to whether the Veteran meets the criteria for a PTSD diagnosis, there is no question that he has a current psychiatric disability. The only matter still in question is whether there is a medical link between the Veteran’s current acquired psychiatric disability and his military service. In this case, the record contains both positive and negative nexus opinions. While the February 2015 VA examiner opined that the Veteran’s psychiatric disability is not related to the Veteran’s military service and is, instead, related to post-service marital problems beginning in July 2014, the August 2018 statement from Dr. A.L.G. noted that the Veteran’s psychiatric problems began as earlier as 2012 and that the Veteran initially used alcohol as a mechanism to self-medicate before pursuing mental health services in 2014. Such is consistent with the record. Furthermore, the continuity of symptomatology evident from the statements from the Veteran, as well as the positive medical nexus opinion discussed above provide a plausible basis to conclude that the Veteran’s current acquired psychiatric disorders are related to his military service. With resolution of all reasonable doubt in the Veteran’s favor, it is concluded that the evidence supports service connection for an acquired psychiatric disorder. 38 U.S.C. § 5107(b). 2. Service connection for a respiratory/pulmonary disorder is denied. The Veteran alleges that he experiences a respiratory/pulmonary disorder secondary to his exposure to burning pits during his military service in Afghanistan. Unfortunately, the Veteran has not provided any additional information regarding this claim, to include the type of respiratory/pulmonary disorder he experiences and/or when this disability was diagnosed. Initially, the Veteran’s service treatment records are negative for a respiratory/pulmonary complaints. Post-service VA treatment records are also negative for respiratory/pulmonary complaints, other than the Veteran’s already service-connected sleep apnea. Significantly, an August 2019 VA treatment record shows a normal respiratory system. The question for the Board is whether the Veteran has a respiratory/pulmonary disorder that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this case, the Board concludes that the Veteran does not have a current diagnosis of a respiratory/pulmonary disorder and has not had such a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). While the Veteran contends that he experiences a respiratory/pulmonary disorder, he has not provided any additional information regarding this claim, to include either the diagnosis or onset. Significantly, his service treatment records are negative for respiratory/pulmonary complaints. Furthermore, while the Veteran has been diagnosed with sleep apnea, the Veteran is already in receipt of service connection for this disability. Also, while the Veteran believes he has a current diagnosis of a respiratory/pulmonary disorder other than sleep apnea, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. To the extent that the Veteran contends these complaints are due to an undiagnosed illness, given the lack of respiratory and pulmonary complaints of record, the Board finds insufficient evidence to require further development of the claim. The Veteran’s mere conclusory generalized lay statement that a service event caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for a respiratory/pulmonary disorder. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability evaluations are based upon VA’s Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007) 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 U.S.C. § 5107 (b); 38 C.F.R. § § 3.102, 4.3. 3. The claim of entitlement to TDIU is dismissed. Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. In February 2020 correspondence, the Veteran indicated that he wished to withdraw his appeal concerning the issue regarding entitlement to a TDIU. Hence, there remain no allegations of errors of fact or law for appellate consideration for this issue. Accordingly, the Board does not have jurisdiction to review the appeal with regard to this issue and it is dismissed. 4. A compensable disability rating for eczematous dermatitis is denied. The Veteran is currently in receipt of a noncompensable disability rating for his eczematous dermatitis under 38 C.F.R. § 4.118, DC 7806. Pursuant to DC 7806, dermatitis or eczema covering less than 5 percent of the entire body, affecting less than 5 percent of exposed areas; and requiring no more than topical therapy during the past 12-month period warrants a noncompensable rating. Dermatitis or eczema covering at least 5 percent, but less than 20 percent, of the entire body; affecting at least 5 percent, but less than 20 percent, of exposed areas; or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12- month period warrants a 10 percent rating. Dermatitis or eczema covering 20 to 40 percent of the entire body, affecting 20 to 40 percent of exposed areas, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent rating. Dermatitis or eczema warrants a 60 percent rating if it covers more than 40 percent of the entire body, more than 40 percent of exposed areas are affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. With respect to the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the Court in Johnson v. McDonald, 27 Vet. App. 497 (2016) held that use of a topical steroid constituted “systemic therapy” within the meaning of DC 7806. In Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit reversed this decision and determined that “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs” under DC 7806 is generally not inclusive of topical corticosteroids. The Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means “treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Thus, according to the Federal Circuit, all applications of topical corticosteroids do not constitute systemic therapy. The Federal Circuit also held that topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. Additionally, dermatitis can alternatively be rated as disfigurement of the head, face or neck (DC 7800) or scars (DC’s 7801-7805) depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7806. By way of history, service connection for eczematous dermatitis was granted by rating decision dated in March 2015 and a noncompensable disability rating was assigned effective July 21, 2014. The Veteran submitted the current claim for an increased rating in May 2015 and a noncompensable disability rating was continued by rating decision dated in November 2015. The Veteran disagreed with this decision and perfected an appeal. Evidence relevant to the level of severity of the Veteran’s eczematous dermatitis includes VA examination reports dated in February and October 2015. During the February 2015 VA examination, the examiner noted a diagnosis of eczematous dermatitis. The Veteran reported that upon returning from Afghanistan in September 2012, he noticed a rash on his knuckles and over the fingers of both hands. He also noticed intermittent blisters and scaling in the knuckles and over the extensor aspect of the fingers of both hands. He treated his condition Mycolog, with improvement. The examiner noted that the Veteran’s skin condition does not cause scarring, benign or malignant neoplasms, or systemic manifestations. The Veteran reportedly treated his condition with topical corticosteroids for a duration of less than six weeks over the past 12 months. There had been no debilitating episodes in the past twelve months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. Physical examination revealed eczema affecting less than 5 percent of the total body area and/or exposed area. Specifically, the examiner noted that at the extensor aspect of the proximal interphalangeal joints and at the knuckles of both hands, there were atrophic patches of skin with mild hyperpigmentation, scaling, and excoriations. There were no other pertinent physical findings. The Veteran’s skin condition did not impact his ability to work. During the October 2015 VA examination, the examiner continued a diagnosis of eczematous dermatitis. The Veteran reported a continued intermittent erythematous pruritic rash in different parts of the body associated with some scaling. He continued to treat this with Mycolog with good results. The examiner noted that the Veteran’s skin condition does not cause scarring, benign or malignant neoplasms, or systemic manifestations. The Veteran reportedly treated his condition with topical corticosteroids for a duration of less than six weeks over the past 12 months. There had been no debilitating episodes in the past twelve months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. Physical examination revealed eczema affecting less than 5 percent of the total body area and/or exposed area. Specifically, the examiner noted that at the extensor aspect of the proximal interphalangeal joints and at the knuckles of both hands, there were atrophic patches of skin with mild hyperpigmentation, scaling, and excoriations. There were no other pertinent physical findings. The Veteran’s skin condition did not impact his ability to work. Also of record are VA treatment records dated through August 2019. Significantly, an August 2019 VA treatment record is negative for skin lesions, dryness, and/or discoloration. In light of the foregoing, the Board finds that the medical evidence of record does not support a compensable disability rating for the Veteran’s eczematous dermatitis. There is no evidence that the Veteran’s skin disorder affects more than 5 percent of the entire body or exposed areas affected. In fact, each of the VA examination reports noted that the total body surface area both involved and exposed was less than 5 percent. Nor is there evidence that the eczematous dermatitis requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. While the Veteran has reportedly been using Mycolog, a topical corticosteroid for treatment of his skin disorder, there is no evidence that his treatment resulted in “systemic therapy” to support a compensable rating. The use of the topical corticosteroid prescribed to the Veteran was applied to less than five percent of his entire body. This more closely approximates “topical therapy” as the corticosteroid used pertains to a certain area of the Veteran’s skin and affects only the area to which it is applied. Such treatment has not been administered on a large enough scale such that it affected the Veteran’s body as a whole. Further, no additional side effects are present, nor are any additional treatment or procedures needed. Accordingly, a compensable disability rating is not warranted for eczematous dermatitis. 5. A 10 percent disability rating for GERD is granted. The Veteran’s GERD, is rated by analogy under 38 C.F.R. § 4.114, DCs 7399-7346. Under DC 7346, a 10 percent evaluation is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation contemplates a level of impairment which includes symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. Note (1) to DC 7346 indicates that abdominal pain in this condition must be confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies. Dysphagia is defined as difficulty in swallowing. Dorland’s Illustrated Medical Dictionary, 587 (31st ed. 2007). Pyrosis is defined as heartburn. Id. at 1587. Hematemesis is defined as the vomiting of blood. Id. at 842. Melena is defined as the passage of dark-colored feces stained with blood pigments or with altered blood. Id. at 1142. By way of history, service connection for GERD as secondary to medications used to treat the Veteran’s service-connected disabilities was granted by rating decision dated in March 2015 and a noncompensable disability rating was assigned effective July 21, 2014. The Veteran submitted the current claim for an increased rating in May 2015 and a noncompensable disability rating was continued by rating decision dated in November 2015. The Veteran disagreed with this decision and perfected an appeal. Evidence relevant to the level of severity of the Veteran’s GERD includes February and October 2015 VA esophageal condition examination reports. During the February 2015 VA examination, the examiner noted a diagnosis of GERD. The Veteran reported that he experienced hyperacidity and reflux in the morning related to the ingestion of his medications. These symptoms started since he was in Afghanistan and began taking Naproxen, a pain medication to treat his service-connected shin splints. The Veteran treated his GERD with over-the-counter antacid medication (Tums) as his symptoms were very mild and well-controlled with Tums. The Veteran experienced both pyrosis and reflux due to his GERD. Physical examination was negative for esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. There were no scars or any other pertinent physical findings. The examiner found that the Veteran’s esophageal condition did not impact his ability to work. During the October 2015 VA examination, the examiner continued a diagnosis of GERD. The Veteran reported that he experienced acidity and reflux and was treating his symptoms with antacid medications. He still had acid reflux, burping (gases), and awakening with acid that reached his throat. The Veteran’s treatment plan included taking continuous medication for his condition, Omeprazole and Ranitidine. The Veteran experienced pyrosis, reflux, and sleep disturbance (caused by esophageal reflux four or more recurrences per year lasting less than one day) due to his GERD. Physical examination was negative for esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. There were no scars or any other pertinent physical findings. The examiner found that the Veteran’s esophageal condition did not impact his ability to work. Also of record are VA treatment records dated through August 2019. Significantly, gastrointestinal examination in August 2019 is negative for dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, and hematochezia. Upon review of the record, the Board finds that a 10 percent rating for GERD is warranted. The records contain evidence of pyrosis (heartburn) and reflux such that acid comes up into his mouth, which more nearly approximates regurgitation. These are two symptoms at the 30 percent level, which allows for a 10 percent rating. Notably, the record is devoid of complaints of dysphagia (difficulty swallowing) and substernal, arm, or shoulder pain that is due to GERD. Also, there is no showing of considerable impairment of health due to GERD. With evidence of two or more of the symptoms for the 30 percent rating of less severity, entitlement to a 10 percent rating is established. In the absence of additional symptoms, however, a higher still rating is not warranted. The Board acknowledges that the Veteran takes prescription medication to control his symptoms and that the Board may not deny a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Here, medication is shown to relieve pyrosis. The symptom of pyrosis is considered in the grant to 10 percent. As such, even considering that the Veteran must take medication, a 10 percent rating, but not higher, is warranted. REASONS FOR REMAND 6. The claim of entitlement to service connection for allergic rhinitis is remanded. The Veteran alleges that he experiences allergic rhinitis secondary to his exposure to burning pits during his military service in Afghanistan. In connection with his initial claim, he was afforded a VA sinuses examination in February 2015. Significantly, the Veteran reported that he suffered from nasal allergies and a runny nose since he was a young boy but, when he went to Kuwait and Afghanistan, he developed chronic sinus congestion. The examiner diagnosed allergic rhinitis as well as chronic sinusitis and opined that the Veteran’s allergic rhinitis was not related to a specific exposure event experienced by the Veteran during his service in Southwest Asia. As rationale for this opinion, the examiner wrote that the Veteran’s allergic rhinitis was a pre-existing condition as the Veteran suffered from allergic rhinitis with symptoms of nasal allergy and rhinorrhea since he was a boy and that the condition did not aggravate beyond its natural course during his deployment. The law provides that Veterans shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Thus, there is a rebuttable presumption of soundness unless a condition is noted at entry. To rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Unfortunately, the Board finds that the February 2015 VA opinion is inadequate. Initially, it is unclear how the February 2015 VA examiner came to the conclusion that the Veteran’s allergic rhinitis clearly and unmistakably pre-existed his military service as pre-enlistment examinations and reports of medical history are negative for allergic rhinitis. Significantly, in a September 2008 report of medical history, the Veteran denied asthma or any breathing problems related to exercise, weather, pollens, etc.” and “sinusitis.” Also, a September 2008 examination report shows normal nose and sinuses. The February 2015 VA examiner also did not provide the necessary opinion of whether there is clear and unmistakable evidence that the Veteran’s allergic rhinitis existed prior to service and/or was not aggravated during service, which is a higher, “onerous” evidentiary standard that must be met by VA. Finally, the February 2015 VA examiner did not provide a medical opinion as to whether the Veteran’s allergic rhinitis is either to secondary to or aggravated by his service-connected sinusitis. As such, on remand, the Veteran should be afforded a new VA examination to determine whether there is “clear and unmistakable evidence” that the Veteran’s allergic rhinitis pre-existed his military service and, if so, whether the pre-existing pes planus was not aggravated by the Veteran’s military service. The examiner should also opine whether the Veteran’s allergic rhinitis is either secondary to and/or aggravated by his service-connected sinusitis. Also, there are likely outstanding VA treatment records as the most recent VA medical records in the claims file are dated in August 2019. Therefore, all outstanding VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated since August 2019. 2. Schedule the Veteran for an appropriate examination to determine the current nature and etiology of his claimed allergic rhinitis. The claims file should be made available for review. Following a review of the record and examination of the Veteran, the examiner is asked to furnish an opinion with respect to the following: a. The examiner should identify whether the Veteran has a current diagnosis of allergic rhinitis. b. The examiner should then opine whether there is clear and unmistakable evidence that the Veteran’s allergic rhinitis existed prior to service. c. If the examiner determines that allergic rhinitis did clearly and unmistakably exist prior to service, the examiner must address whether there is clear and unmistakable (undebatable, obvious, or manifest) evidence that the disability was not aggravated by such service. Note: Aggravation means that the disability was permanently worsened beyond the natural progression of the disease; temporary or intermittent flare-ups of a preexisting injury during service are insufficient to constitute aggravation in service, unless the underlying condition itself, as contrasted with mere symptoms, has worsened. In addressing the above, the physician should consider and discuss all relevant medical and other objective evidence, including the following: (i) a September 2008 report of medical history wherein the Veteran denied asthma or any breathing problems related to exercise, weather, pollens, etc.” and “sinusitis,” (ii) a September 2008 examination report shows normal nose and sinuses, and (iii) the February 2015 VA sinuses examination showing that the Veteran suffered from nasal allergies and a runny nose since he was a young boy. See VBMS, document labeled STR – Reserve STR, receipt date 1/13/2015, pages 29 and 39; VBMS, document labeled C&P Exam, receipt date 2/20/2015, page 1. d. If the examiner determines there is clear and unmistakable evidence that allergic rhinitis existed prior to service and clear and unmistakable evidence that the allergic rhinitis was not aggravated by such service, the examiner must opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that allergic rhinitis was incurred in or is otherwise related to his military service. e. If the examiner determines there is clear and unmistakable evidence that allergic rhinitis existed prior to service and clear and unmistakable evidence that the allergic rhinitis was not aggravated by such service, the examiner must opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that allergic rhinitis was aggravated by his service-connected sinusitis disability. Note that in this context, aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The underlying reasons for the opinions reached must be included. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board April Maddox, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.