Citation Nr: 20021676 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 19-17 328 DATE: March 26, 2020 ORDER The appeal seeking to reopen a claim of service connection for a lower back condition is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for a blood condition is denied. Entitlement to service connection for a dental condition is denied. Entitlement to a disability rating of 50 percent for headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a compensable disability rating for a surgical scar on the abdomen is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted. Entitlement to an earlier effective date for an increased rating for irritable bowel syndrome, gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy is dismissed. Entitlement to an earlier effective date for an increased rating for a surgical scar on the abdomen is dismissed. REMANDED Entitlement to service connection for a finger condition is denied. Entitlement to a disability rating in excess of 10 percent for irritable bowel syndrome, gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy is denied. Entitlement to a disability rating in excess of 70 percent for persistent depressive disorder is remanded. Entitlement to a disability rating in excess of 20 percent for right knee ilio-tibial band syndrome is remanded. FINDINGS OF FACT 1. In an April 2010 rating decision, the claim of entitlement to service connection for a lower back condition was denied because the evidence did not show a permanent residual or chronic disability subject to service connection. The Veteran did not appeal that decision or submit new and material evidence within one year; it became final. 2. The evidence added to the record since the April 2010 rating decision does not relate to an unestablished fact that is necessary to substantiate the claim of entitlement to service connection for a lower back condition. 3. The Veteran’s tinnitus was incurred during his active duty service. 4. The preponderance of the evidence of record is against finding that the Veteran has had sleep apnea, or either a blood or dental condition at any time during or approximate to the pendency of the claim. 5. Throughout the appeal period, the Veteran had migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 6. The Veteran’s service-connected abdominal scar was smaller than 12 square inches (77 sq. cm.), was not unstable or painful, and otherwise did not impair function at any time during the pendency of the appeal. 7. The Veteran is precluded from substantially gainful employment, consistent with his education and occupational experience, as a result of his service-connected disabilities. 8. The claims for earlier effective dates pertaining to increased ratings for gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy and a surgical scar on the abdomen are freestanding earlier effective date claims. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim for entitlement to service connection for a lower back condition. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 2. The criteria for entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for a blood condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for a dental condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for a disability rating of 50 percent, but no greater, for headaches have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.124a, Diagnostic Code (DC) 8100. 7. The criteria for entitlement to a disability rating in excess of 10 percent for a service-connected abdominal scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.27, 4.118, Diagnostics Code (DC) 7802. 8. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16(a), 4.25. 9. Entitlement to an earlier effective date for the grant of an increased rating for gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy is dismissed. 38 U.S.C. § 7266; 38 C.F.R. § 20.1103; Rudd v. Nicholson, 20 Vet. App. 296 (2006). 10. Entitlement to an earlier effective date for the grant of an increased rating for a surgical scar on the abdomen is dismissed. 38 U.S.C. § 7266; 38 C.F.R. § 20.1103; Rudd v. Nicholson, 20 Vet. App. 296 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2007 to September 2009. On his May 2018 Notice of Disagreement, the Veteran checked the boxes indicating he was disagreeing with both the effective dates and the evaluations of both his service-connected persistent depressive disorder, as well as his right knee ilio-tibial band syndrome. Subsequently, in a September 2019 rating decision, he was granted higher evaluations for the two disabilities, each effective June 1, 2017. In his September 2019 VA Form 9 appeal, the Veteran again maintained that he was entitled to both earlier effective dates and increased evaluations for the respective disabilities. As the Veteran’s claims for increased ratings for these two disabilities both remain on appeal, the claims for earlier effective dates are encompassed within the increased rating claims on appeal. New and Material Evidence Whether new and material evidence has been submitted sufficient to reopen a claim for entitlement to service connection for a lower back condition The Veteran seeks to reopen a previously denied claim seeking entitlement to service connection. The question before the Board is whether new and material evidence has been submitted to reopen the claim. The Board finds that new and material evidence has not been received sufficient to reopen his claim. The Veteran’s original claim of service connection for a lower back condition was initially denied in an April 2010 rating decision because the RO found that the evidence did not show a permanent residual or chronic disability subject to service connection. The Veteran did not appeal that decision or submit new and material evidence within one year; it became final. In November 2017, the Veteran filed his current petition to reopen the claim seeking service connection. Evidence received since the last final April 2010 rating decision includes numerous VA and private medical records. The medical records were not of record at the time of the April 2010 rating decision, and therefore, the VA and private treatment records are new. However, none of this recently submitted evidence relates the Veteran’s reports of back pain to his active duty service or suggests that the Veteran’s current back complaints may be associated with his active duty service. As such, the Board finds that these medical records are not material. The Veteran has not provided any specific statements explaining why he believes he is entitled to this benefit beside his petition seeking to reopen the claim. To the extent that his petition to reopen his previously denied claim can be interpreted as a statement asserting that his back problems are related to service, this statement would be the same as those the Veteran made prior to the April 2010 final denial. Further, the Veteran’s reports of back pain are the same as statements he made prior to the April 2010 rating decision. As such, these statements are not new. Accordingly, the Board finds that new and material evidence has not been received to reopen the Veteran’s service connection claim for a lower back condition, and the appeal is denied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Shade v. Shinseki, 24 Vet. App. 110 (2010). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d); Cosman v. Principi, 3 Vet. App. 503 (1992). 1. Entitlement to service connection for tinnitus The Veteran contends that he began experiencing symptoms of tinnitus during active duty service. The Board concludes that the Veteran has tinnitus that is related to conceded noise exposure in service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). For VA purposes, tinnitus has been specifically found to be a disorder with symptoms that can be identified through lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran’s DD-214 reflects that his military occupational specialty was motor transport operator. Military noise exposure is therefore conceded. At his March 2018 VA examination, the Veteran reported experiencing recurrent tinnitus that began in 2007 with a gradual onset. The examiner concluded it was less likely than not that tinnitus was caused by or a result of military noise exposure. However, the Board finds the opinion inadequate to adjudicate the Veteran’s claim because the examiner based the opinion, in part, on an absence of service treatment records documenting complaints of tinnitus in service. An opinion based on the absence of treatment records without consideration of a Veteran’s competent reports is inadequate. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The Veteran testified that tinnitus began during service is consistent with the circumstances of his service. There is no evidence in the record that contradicts the Veteran’s competent and credible testimony regarding the onset and progression of his symptoms. The evidence regarding the onset of tinnitus is in equipoise. Thus, affording the Veteran the benefit of the doubt, entitlement to service connection for tinnitus is granted. 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for sleep apnea 3. Entitlement to service connection for a blood condition 4. Entitlement to service connection for a dental condition The Veteran generally contends that he suffers from sleep apnea, as well as blood, dental and finger conditions that are the result of his active duty service. For the reasons that follow, the Board finds that service connection is not warranted for any of these respective claims, and they are denied. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis related to his claims of sleep apnea, blood, dental and finger conditions, and he has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). A review of the Veteran’s available post-service medical records does not show any indication that he has ever been diagnosed, sought medical treatment for, or suffered from symptoms of any of the above-noted conditions at any point during the period on appeal. Besides the general assertions the Veteran has made claiming service connection, neither he nor his representative have provided any explanation for why the Veteran believes he is entitled to service connection, nor have they delineated what symptoms the Veteran suffers from that would entitle him to service connection for any of the respective conditions. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). Congress has specifically limited entitlement to service connection for disease or injury to cases where such in-service events have resulted in a current disability. See 38 U.S.C. § 1110. Thus, without “competent evidence of current disability,” there can be no award of service connection. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Based on a careful review of the evidence, the Board finds that service connection is not warranted for any of the above-noted conditions as the evidence in the record weighs against a finding of a current diagnosis during the period on appeal. As the preponderance of the evidence is against the Veteran’s claims, the benefit-of-the-doubt rule does not apply, and his service connection claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Regulations require that where there is a question as to which of two evaluations is to 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. 1. Entitlement to a compensable disability rating for headaches The Veteran contends that he is entitled to a higher disability rating for his headache disability. Having reviewed the record, the Board will resolve doubt in the Veteran’s favor and find that an increased disability rating of 50 percent is warranted for headaches. Under the Rating Schedule, Diagnostic Code (DC) 8100 provides that migraines: with less frequent attacks warrants a noncompensable rating. 38 C.F.R. § 4.124a. Under DC 8100, migraines with characteristic prostrating attacks averaging one in 2 months over last several months warrant a 10 percent rating. Migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months are rated as 30 percent. A maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks that produce severe economic inadaptability. The phrase “characteristic prostrating attacks” was defined as describing migraine attacks that typically produce powerlessness or a lack of vitality. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The distinction between the 10 and 30 percent disability levels is the frequency of the headaches. A 10 percent rating is warranted when the prostrating headaches occur once every 2 months; 30 percent when the prostrating headaches occur once a month. The 50 percent rating does not specify the frequency of prostrating headaches, but the phrase “very frequent” connotes a frequency greater than once a month. Johnson, 30 Vet. App. at 253. Thus, to assign a 50 percent rating, the headaches would have to be very frequent and produce severe economic inadaptability. DC 8100. The evidence indicates that the Veteran’s headaches manifested with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A February 2018 VA examination indicated that the Veteran’s headaches did not result in characteristic prostrating attacks, but instead resulted in pulsating or throbbing head pain, pain on both sides of the head, and sensitivity to light. However, the Board finds that the preponderance of the medical evidence indicates the opposite. In the same February 2018 VA examination report, the Veteran reported experiencing headaches approximately one to two times per week, he took Tylenol to treat his symptoms, and he had to lie down and wait for his headaches to go away. In an August 2019 letter, the Veteran’s mother reported that his headaches prevented him from being able to sleep. In another letter dated the same day, the Veteran’s brother stated that he has overheard the Veteran telling his mother “all the time” that he has a headache, and that the Veteran stated he got dizzy and nauseous. In a November 2019 private evaluation was based on a review of the record and interview with the Veteran. In that evaluation, the Veteran again reported experiencing one to two headaches a week that required him to go lie down in a dark, quiet room for relief. The Veteran stated his symptoms lasted anywhere from two to nine hours, and that when these headaches occurred, they were a seven out of 10 in severity. The private examiner found the Veteran experienced prostrating attacks of migraine headache pain more frequently than once per month. The opinion provider also concluded that the Veteran would be required to miss or leave work early three or more days per month due to headaches. Affording the Veteran the benefit of the doubt, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran’s headaches manifested with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Accordingly, a 50 percent disability is warranted for headaches. 2. Entitlement to a compensable disability rating for a surgical scar on the abdomen The Veteran seeks an increased evaluation for his service-connected scar disability. The Board finds that a higher rating is not warranted, and the claim is denied. The Veteran’s abdominal scar is evaluated pursuant to 38 C.F.R. § 4.118, DC 7802. Under Diagnostic Code 7801, scars, other than the head, face, or neck, that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, scars, other than the head, face, or neck, that are superficial and nonlinear that are of an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent disability rating. A superficial scar is not one associated with underlying soft tissue damage. See Note (1). Diagnostic Code 7804 provides that unstable or painful scars are rated as follows: 10 percent for one or two scars; 20 percent for three or four scars; and 30 percent for five or more scars. 38 C.F.R. § 4.118. Diagnostic Code 7805 directs that any other disabling effects of a scar not described in Code 7802 or 7804, are to be evaluated under an appropriate Diagnostic Code. Turning to the evidence of record, a July 2019 VA examination noted the Veteran had a linear scar on the middle of his abdomen measuring 18 centimeters by 3 centimeters. A separate scars examination report noted the examiner’s finding that the scar was not painful or unstable, with frequent loss of covering of skin over the scar. The examiner also found that the scar did not result in any limitation of function or impact the Veteran’s ability to work. A review of the remaining medical evidence of record does not show any medical findings or other evaluation of the Veteran’s scar disability. The Board finds that at no point during the appeal period was the Veteran’s abdominal scar found to measure an area of at least 12 square inches (77 sq. cm.). The scar was also never found to be unstable or painful, and it did not result in any functional limitations. The Veteran himself has not provided any lay assertions that his scar has caused him any functional limitations. Accordingly, the Board finds that a compensable rating is not warranted for the Veteran’s surgical scar. 3. Entitlement to a TDIU is granted. Entitlement to TDIU has been raised as part of the increased rating claims before the Board. See VA Form 21-8940, Application for TDIU submitted in January 2020; Rice v. Shinseki, 22 Vet. App. 447 (2009). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. A total rating based on unemployability due to service-connected disabilities may be granted if the service-connected disabilities preclude the Veteran from obtaining or maintaining substantially gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran has met the schedular criteria for TDIU for the entire appeal period. 38 C.F.R. § 4.16(a). His service-connected disabilities are depressive disorder, evaluated as 70 percent disabling; headaches, now evaluated at 50 percent; right knee, 20 percent, IBS, 10 percent; abdominal scar, 20 percent, and; psoriasis, 10 percent. On his VA Form 21-8940, the Veteran reported completing high school, that he last worked full-time in June 2009 and had a job history after service of dishwasher and stocker. An October 2019 Social Security Administration letter detailing the Veteran’s earnings record from 2001 through 2017 shows no earnings for the years 2010 to 2017. The Board finds that the evidence of record supports entitlement to a TDIU. The functional impact of his IBS includes the need to be close to a restroom because of diarrhea. See 2018 VA examination. His headache disability has been manifested by prostrating attacks of migraine headache pain more frequently than once per month and would result in the Veteran having to miss or leave work early three or more days per month due to headaches. See November 2019 evaluation. His depressive disorder has been determined to result in significant occupational impairment. Considering the Veteran’s level of education and his relevant work history as a dishwasher and stocker, the Board finds the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Entitlement to a TDIU is warranted. Earlier Effective Date 1. Entitlement to an earlier effective date for an increased rating for gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy 2. Entitlement to an earlier effective date for an increased rating for a surgical scar on the abdomen The Veteran seeks earlier effective dates for the award of increased ratings for the above-noted disabilities. The Board finds that it does not have jurisdiction to adjudicate these freestanding claims. The Veteran’s claims are therefore dismissed. In his May 2018 Notice of Disagreement, the Veteran checked the box for disagreement with the area of the effective date for gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy, as well as his service-connected abdominal scar. Neither the Veteran nor his attorney have made any specific contentions about these effective dates. The Veteran filed his claim for benefits in June 2017 and increased evaluations for the two disabilities were denied in the September 2017 rating decision. He has been in receipt of a 10 percent evaluation for his service-connected gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy effective September 15, 2009, and he has received a 10 percent evaluation for his abdominal scar effective from the same date. As no increased evaluations were granted for either of the Veteran’s disabilities, earlier effective dates are not available. The Board cannot adjudicate these earlier effective date claims as they represent freestanding claims for earlier effective dates, which are not permitted. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). These claims for earlier effective dates are therefore dismissed for lack of jurisdiction. See 38 U.S.C. § 7105 (d)(5). Should any higher ratings be granted in the future for these conditions, any assigned effective date can thereafter be appealed. REASONS FOR REMAND 1. Entitlement to service connection for a finger condition In March 2018, the Veteran underwent a VA hand and finger conditions examination to evaluate the etiology of his claimed finger disability. At his examination, the Veteran reported experiencing pain and swelling to his hands since being diagnosed with his now service-connected psoriasis. The examination report noted that the Veteran’s hands had abnormal range of motion in the fingers. The report did not document any specific statements from the Veteran about his claimed finger disability, but simply noted his reports of pain and hand swelling since being diagnosed with psoriasis. The examiner also provided no opinion on the Veteran’s claimed finger disability. Remand is needed for a more thorough examination with etiology opinion on this issue. 2. Entitlement to a disability rating in excess of 10 percent for irritable bowel syndrome, gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy The Veteran’s disability is rated pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7346-7319. The evaluation is reflective of both the Veteran’s reports and medical evidence showing that his irritable bowel syndrome appears to be the predominant disability. He was afforded VA examinations in March 2018 and July 2019 to evaluate the current severity of his disability. However, the examination reports fail to adequately assess the full extent of the Veteran’s symptoms, notably his consistent reports of diarrhea, nausea and cramping. For instance, a June 2017 VA primary care note documented the Veteran’s reports of developing “explosive watery diarrhea and cramping” after eating. A March 2018 VA esophageal conditions examination also noted the Veteran’s reports of diarrhea and cramping when traveling. However, these symptoms are not addressed in a July 2019 VA intestinal conditions examination report. Remand is needed to afford the Veteran an examination with more thorough findings on the present severity of his disability that takes into consideration his reports and the medical evidence. 3. Entitlement to a disability rating in excess of 70 percent for persistent depressive disorder is remanded. A review of the Veteran’s VA treatment records show that the Veteran has been receiving mental health counseling from a private medical provider. See, e.g., September 2017 VA primary care nursing note. Remand is needed to obtain these outstanding records, as they may provide more detailed information on the severity of the Veteran’s psychiatric disability. 4. Entitlement to a disability rating in excess of 20 percent for right knee ilio-tibial band syndrome is remanded. While the record contains a VA examination dated in July 2019 regarding the Veteran’s right knee ilio-tibial band syndrome, the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26 (2017), in terms of any additional functional loss suffered during flare-ups of the Veteran’s disability. Despite the Veteran’s reports stating he experienced flare-ups, the July 2019 VA examiner did not address how these reported flare-ups would affect the Veteran’s disability. Specifically, in an area of the examination report meant to document the severity of flare-ups, the examiner simply wrote “severe.” Also, in estimating the range of motion of the Veteran’s right knee during flare-ups, the examiner provided range of motion estimates – without any explanation as to how these figures were derived – that were indicative of less functional impairment than the measurements of the right knee taken during at the time of the examination. The July 2019 VA examination also does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016). Remand is needed for a new VA examination with more thorough findings in compliance with both Sharp and Correia. As these issues are being remanded for further development, the Veteran’s claims folder should also be updated to include all outstanding VA treatment records. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated from May 2016 to the present and associate those documents with the Veteran’s claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for all private medical providers, to include Marcia McGlone and Counseling Assoc. Inc. Make two requests for the authorized records from all listed private medical providers, unless it is clear after the first request that a second request would be futile. 3. After completing the above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed finger condition. The examiner must determine whether the Veteran has any current finger disorder, which may include pain alone that rises to the level of functional impairment. Based on the examination and review of the record, the examiner should answer the following: (a.) Identify any diagnosed finger disorder (which may include pain alone that rises to the level of functional impairment). (b.) Is it at least as likely as not that any currently diagnosed finger disability either had its onset in or is otherwise related to an in-service injury, event, or disease? (c.) Is it at least as likely as not that any currently diagnosed finger disability was caused or aggravated by the Veteran’s service-connected psoriasis? A complete rationale must be provided for all opinions. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected irritable bowel syndrome, gastroesophageal reflux disease, duodenal ulcer, and cholecystectomy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right knee ilio-tibial band syndrome. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). M. E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jack S. Komperda, 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.