Citation Nr: 20028830 Decision Date: 04/24/20 Archive Date: 04/24/20 DOCKET NO. 08-36 338 DATE: April 24, 2020 ORDER Entitlement to a 10 percent initial rating for hypertension is granted. Entitlement to a compensable initial rating for migraine headaches, prior to April 26, 2017, is denied. Entitlement to an initial disability rating in excess of 50 percent for migraine headaches, from April 26, 2017, is denied. Entitlement to a compensable initial rating for carpal tunnel syndrome, right wrist, hand, and elbow, prior to September 17, 2012, is denied. Entitlement to an initial disability rating in excess of 10 percent for carpal tunnel syndrome, right wrist, hand, and elbow, from September 17, 2012, is denied. REMANDED The issue of entitlement to service connection for a low back disability is remanded. The issue of entitlement to service connection for residuals of hyperprolactinemia and premature ovarian failure is remanded. The issue of entitlement to service connection for an eye disorder, claimed as blurred vision, is remanded. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The objective clinical findings reflect that throughout the rating period, the Veteran has been on continuous medication for control of hypertension, without objective demonstration of a history of diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. 2. The most probative evidence of record does not show that, prior to April 26, 2017, the Veteran’s migraine headaches were manifested by characteristic prostrating attacks averaging one in two months over last several months. 3. For the rating period from April 26, 2017, the Veteran is in receipt of a disability rating of 50 percent for migraine headaches, which is the maximum schedular rating for that disability. 4. Prior to September 17, 2012, the Veteran’s carpal tunnel syndrome, right wrist, hand, and elbow was not manifested by mild incomplete paralysis of the major extremity. 5. From September 17, 2012, the Veteran’s carpal tunnel syndrome, right wrist, hand, and elbow has been manifested by no more than mild incomplete paralysis of the major extremity. CONCLUSIONS OF LAW 1. The criteria for a 10 percent initial rating for hypertension have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code 7101. 2. The criteria for a compensable initial rating, prior to April 26, 2017, for service-connected migraine headaches have not been met. 38 U.S.C. §§ 1154 (a), 5107; 38 C.F.R. §§ 3.321 (b), 4.124a, Diagnostic Code 8100. 3. The criteria for an initial disability rating in excess of 50 percent, from April 26, 2017, for service-connected migraine headaches have not been met. 38 U.S.C. §§ 1154 (a), 5107; 38 C.F.R. §§ 3.321 (b), 4.124a, Diagnostic Code 8100. 4. The criteria for entitlement to a compensable initial rating for carpal tunnel syndrome, right wrist, hand, and elbow, prior to September 17, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.400, 4.3, 4.7, 4.14, 4.21, 4.124a, Diagnostic Code 8515. 5. The criteria for entitlement to an initial disability rating in excess of 10 percent for carpal tunnel syndrome, right wrist, hand, and elbow, from September 17, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.400, 4.3, 4.7, 4.14, 4.21, 4.124a, Diagnostic Code 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1986 to February 2007. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a May 2007 and October 2009 (blurred vision) rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in May 2016 and December 2017. The case has been returned to the Board for review. In a March 2013 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran’s carpal tunnel syndrome, right wrist and hand to 10 percent disabling, effective September 2012. In a May 2017 rating decision the AOJ increased the rating for the Veteran’s migraine headaches to 50 percent disabling, effective April 26, 2017. As the increases did not satisfy the appeals in full, the issues remain on appeal and have been characterized as shown above. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified at a videoconference hearing before a Veterans Law Judge (VLJ) of the Board in February 2016. The law requires that the VLJ who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C. § 7107 (c); 38 C.F.R. § 20.707. However, the VLJ who conducted the February 2016 Board hearing is no longer employed by the Board. In February 2020, the Veteran and her representative were sent a letter notifying them that the VLJ who presided over the February 2016 hearing is no longer employed by the Board, and offering another hearing before a different VLJ. The letter noted that the Veteran had 30 days from the date of the letter to respond or the Board will assume that she did not want another hearing and proceed accordingly. The Veteran did not respond to the February 2020 letter. A transcript of the February 2016 Board hearing is of record. As such, the Board will consider the case on the evidence of record. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. at 452-54. In this case the Veteran asserted that her service-connected cubital tunnel syndrome of the right elbow and carpal tunnel syndrome of the right wrist, in part, led to her retirement. The Board interprets this statement as an indication that the Veteran feels she is unable to secure or follow a substantially gainful occupation as a result of the service-connected disabilities at issue on appeal. Accordingly, the Board finds that a claim for a TDIU has been raised as part and parcel to the increased rating claim. Therefore, the issue of entitlement to a TDIU is before the Board on appeal and is properly included in the list of issues before the Board. Increased Ratings Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 1. Entitlement to a Compensable Initial Rating for Hypertension The Veteran seeks a compensable initial rating for her service-connected hypertension. The Veteran’s service-connected hypertension is rated as noncompensable under 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran’s hypertension has been rated as noncompensable effective from March 1, 2007, the day following her separation from active service. The applicable rating period is from March 1, 2007, the effective date for the award of service connection for hypertension through the present. See 38 C.F.R. § 3.400. Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more; or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A maximum 60 percent rating is warranted for diastolic pressure predominantly 130 or more. Turning to the relevant evidence of record, the Veteran was provided a VA examination in February 2007. The VA examination reflects that the Veteran takes medication for her hypertension and she demonstrated blood pressure readings of 134/100, 129/86, and 134/94. A March 2011 VA treatment record reflects a blood pressure reading of 144/97. A June 2011 VA treatment record reflects a blood pressure reading of 158/101. July 2011 VA treatment records reflect blood pressure readings of 132/90 and 143/90. A November 2011 VA treatment record reflects a blood pressure reading of 127/81. A December 2011 VA treatment record reflects a blood pressure reading of 136/89. The Veteran was provided a VA examination in September 2012. The VA examiner noted that the Veteran takes medication for her hypertension. Upon examination, the Veteran demonstrated blood pressure readings of 156/100, 148/98, and 143/95. An April 2013 VA treatment record reflects a blood pressure reading of 129/86. A May 2013 VA treatment record reflects a blood pressure reading of 124/86. A June 2014 VA treatment record reflects a blood pressure reading of 108/88. The Veteran was provided a VA examination in April 2017. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The VA examiner noted that the Veteran takes medication for her hypertension. Upon examination, the Veteran demonstrated blood pressure readings of 132/90, 132/92, and 136/92. The Veteran was provided a VA examination in January 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. Upon examination, the Veteran demonstrated blood pressure readings of 140/90, 132/92, and 130/88. The evidence of record does not show any systolic pressure readings of 160 or more during the rating period. Also, the Veteran’s diastolic pressure readings have predominantly been lower than 100 throughout the rating period. That said, it is clear from the Veteran’s history that she is prescribed medication for hypertension, and there is insufficient documentation of record to suggest that her diastolic pressure would not have been predominantly 100 or more, or her systolic pressure predominantly 160 or more, but for the medication. The disability picture that emerges is one of a hypertension disability that medication keeps below the threshold represented by the criteria for a 10 percent rating. Resolving all doubt in the Veteran’s favor, the Board finds that a 10 percent initial evaluation, but not more, is warranted for the Veteran’s hypertension. To that extent, the appeal is granted. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to Higher Staged Initial Ratings for Migraine Headaches The Veteran seeks higher initial ratings for her service-connected migraine headaches. The Veteran’s service-connected migraine headaches are rated as noncompensable prior to April 26, 2017, and 50 percent disabling from April 26, 2017 under 38 C.F.R. § 4.124a, Diagnostic Code 8100. The applicable rating period is from March 1, 2007, the effective date for the award of service connection for migraine headaches through the present. See 38 C.F.R. § 3.400. Under Diagnostic Code 8100 a 10 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once in 2 months over the last several months; a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months; and a maximum 50 percent schedular rating is warranted for migraines with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability. The rating criteria do not define “prostrating.” By way of reference, the Board notes that DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32nd Ed. 2012), defines “prostration” as “extreme exhaustion or powerlessness.” Turning to the relevant evidence of record, the Veteran’s medical treatment records do not include findings relevant to rating the Veteran’s migraine headaches under Diagnostic Code 8100. They reflect that the Veteran endorsed headache pain, however, they do not indicate or suggest that the headaches included characteristic prostrating attacks. The Veteran was provided a VA examination in February 2007. The Veteran reported severe headache flare-ups that occur four times a year, lasting three days. She further reported that they are alleviated with sleep and quiet dark rooms. The Veteran reported pain, photosensitivity, phonosensitivity, and nausea. The Veteran reported that the attacks are prostrating in nature and ordinary activity is impossible. The Veteran was provided a VA examination in September 2012. The Veteran reported migraine headaches every other week. She reported pain on both sides of the head, nausea, and sensitivity to light. The Veteran further reported the duration of typical head pain is more than two days. The VA examiner noted that the Veteran has characteristic prostrating attacks of migraine headache pain less than once every two months. The Veteran was provided a VA examination in March 2015. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that her migraine headaches have reduced since she began receiving Botox injections every twelve weeks as a preventative measure. The Veteran reported one to two headaches per month. She reported headache pain on both sides of the head that last less than one day. The VA examiner noted that the Veteran does not have characteristic prostrating attacks of migraine/non-migraine headache pain. The Veteran was provided a VA examination in April 2017. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported pulsating or throbbing head pain on both sides of the head that worsens with physical activity. She reported non-headache symptoms of nausea, sensitivity to light, sensitivity to sound, changes in vision, sensory changes and dry heaves. The Veteran further reported typical head pain lasts more than two days. The VA examiner noted that the Veteran has characteristic prostrating attacks of migraine/non-migraine headache pain once every month. The VA examiner noted that the Veteran has very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. The Veteran was provided a VA examination in January 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported migraine headaches several times a week. She reported pain on both sides of the head and non-headache symptoms of nausea, sensitivity to light and sensitivity to sound. The VA examiner reported that the Veteran has characteristic prostrating attacks of migraine/non-migraine headache pain more frequently than once per month. The VA examiner further reported that the Veteran has very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. In view of the relevant evidence of record, the Board concludes that prior to April 26, 2017, the Veteran was not entitled to a compensable initial rating for her service-connected migraine headaches. The medical treatment records do not indicate that the Veteran had characteristic prostrating headache attacks averaging one in two months over the last several months. At the February 2007 VA examination, the Veteran reported prostrating headaches, however, there is no indication of the frequency of her prostrating migraine headaches. The September 2012 VA examiner noted that the Veteran has characteristic prostrating attacks of migraine headache pain less than once every two months. The March 2015 VA examiner noted that the Veteran does not have characteristic prostrating attacks of migraine/non-migraine headache pain. Such symptoms do not more closely approximate the severity contemplated by the criteria for a 10 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8100, which requires a minimum of characteristic prostrating attacks averaging one in two months over the last several months. There is no probative evidence of record that the Veteran experienced prostrating headache attacks contemplated for a 10 percent rating, prior to April 26, 2017. As to whether the Veteran is entitled to an initial rating in excess of 50 percent for migraine headaches from April 26, 2017, the Board notes that 50 percent is the maximum schedular rating available for headaches under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Therefore, the Veteran is not entitled to a schedular rating in excess of 50 percent for headaches at any time during the rating period from April 26, 2017. In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature and severity of her service-connected migraine headaches at issue, and notes that her lay testimony is competent to describe certain symptoms associated with this disability. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran’s statements with regard to the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for higher staged initial disability ratings for the Veteran’s migraine headaches have not been met at any time during the rating period. To the extent the Veteran seeks higher staged initial disability ratings, the preponderance of the evidence is against the assignment of higher staged initial disability ratings, the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to Higher Initial Ratings for Carpal Tunnel Syndrome, Right Wrist, Hand, and Elbow The Veteran seeks higher staged initial ratings for her service-connected carpal tunnel syndrome, right wrist, hand, and elbow. The Veteran’s service-connected carpal tunnel syndrome is rated as noncompensable prior to September 17, 2012, and 10 percent from September 17, 2012, under 38 C.F.R. § 4.124a, Diagnostic Code 8515. The applicable rating period is from March 1, 2007, the effective date for the award of service connection for carpal tunnel syndrome through the present. See 38 C.F.R. § 3.400. Diagnostic Code 8515 provides ratings for complete and incomplete paralysis of both the “minor” and the “major” extremities. The Veteran is dominant on the right side. Under Diagnostic Code 8515, evidence of mild incomplete paralysis warrants a 10 percent rating for the dominant extremity. Evidence of moderate incomplete paralysis warrants a 30 percent rating for the dominant extremity. Evidence of severe incomplete paralysis warrants a 50 percent rating for the dominant extremity. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Turning to the relevant evidence of record, the Veteran was provided a VA examination in February 2007. The Veteran reported wrist and elbow pain. The Veteran reported flare-ups of right wrist pain twice a week, lasting two days, that are moderate in severity. Upon examination, the Veteran’s right upper extremity reflexes were equal to the left upper extremity. Both the Tinel’s sign and Phalen’s test were negative and sensation was normal. The Veteran was provided a VA examination in September 2012. The VA examiner noted that the Veteran is right hand dominant. The Veteran reported pain every other day in her right elbow of a seven out of ten. She reported numbness/tingling down her right arm. The Veteran reported flare-ups once a week of a seven out of ten on the pain scale that lasts two to three hours. Upon examination, the Veteran demonstrated right elbow flexion of 145 or greater with no objective evidence of painful motion and extension to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing without additional loss of range of motion. The Veteran demonstrated normal strength in the elbow upon flexion and extension. As to her right wrist, the Veteran reported pain every other day of an eight out of ten. She further reported difficulty with grip and numbness/tingling pain. Upon examination, the Veteran demonstrated right wrist palmar flexion to 75 degrees with no objective evidence of painful motion. She demonstrated normal strength of the right wrist. The VA examiner stated that the Veteran has mild right carpal tunnel syndrome with no functional limitation. The Veteran was provided a VA peripheral nerves condition examination in April 2017. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported pain in the right wrist and pain, numbness, tingling, and coldness in the right arm from the elbow to fingers. The VA examiner reported that the Veteran does not have constant pain in the right upper extremity and has mild intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the right upper extremity. The VA examiner noted that the Veteran had mild incomplete paralysis of the right median nerve and right ulnar nerve. The Veteran was provided a VA peripheral nerves condition examination in January 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported right wrist and elbow pain with occasional numbness and tingling. The examiner noted mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the right upper extremity. The Veteran did not demonstrate constant pain of the right upper extremity. Upon examination the Veteran demonstrated normal muscle strength, normal reflexes and normal sensory of the right upper extremity. The VA examiner noted that the Veteran had mild incomplete paralysis of the right median nerve. In view of the relevant evidence of record, the Board concludes that prior to September 17, 2012, the Veteran was not entitled to a compensable initial rating for her service-connected carpal tunnel syndrome, right wrist, hand, and elbow. At the February 2007 VA examination, both the Tinel’s sign and Phalen’s test were negative and sensation was normal. Such symptoms do not more closely approximate the severity contemplated by the criteria for a 10 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8515, which require a minimum of mild incomplete paralysis of the major extremity. As such, a compensable initial rating for the Veteran’s service-connected carpal tunnel syndrome was not met prior to September 17, 2012. From September 17, 2012, the Board concludes that the Veteran is not entitled to a rating in excess of 10 percent. At both the April 2017 and January 2019 VA examination’s the Veteran reported mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the right upper extremity. Additionally, the VA examiners noted that the Veteran had mild incomplete paralysis of the right upper extremity. Such symptoms do not more closely approximate the severity contemplated by the criteria for a 20 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8515, which require a minimum of moderate incomplete paralysis of the major extremity. As such, a 20 percent initial rating for the Veteran’s service-connected carpal tunnel syndrome was not met from September 17, 2012. In addition, there is no probative evidence of record or allegation in support of application of any other diagnostic code for the Veteran’s service-connected carpal tunnel syndrome. Therefore, no diagnostic code will be applied other than Diagnostic Code 8515. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature and severity of her service-connected carpal tunnel syndrome at issue, and notes that her lay testimony is competent to describe certain symptoms associated with this disability. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and are noted to be contemplated by the criteria for the disability rating for which the Veteran has been found entitled by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran’s statements with regard to the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. The Board therefore finds that the criteria for a compensable initial rating prior to September 17, 2012, and in excess of 10 percent from September 17, 2012, for the Veteran’s service-connected carpal tunnel syndrome, right wrist, hand, and elbow have not been met at any time during the rating periods. Accordingly, there is no basis for additional staged ratings of the Veteran’s carpal tunnel syndrome pursuant to Fenderson, 12 Vet. App. at 126-27, and higher ratings must be denied. As the preponderance of the evidence is against the assignment of higher staged initial ratings, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Ver. App. 49 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to Service Connection for a Low Back Disability The Veteran contends that she has a low back disability that is directly related to her active service. Specifically, the Veteran reported that she suffered from low back pain during her active service and the pain has continued to the present. See, e.g., September 2019 correspondence. The Veteran was provided a VA examination as to her low back condition in January 2019. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the January 2019 VA examination is inadequate for decision-making purposes. The VA examiner diagnosed the Veteran with lumbosacral strain and opined that the disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As rationale, the VA examiner stated that since the Veteran’s February 2007 separation examination, there has been no mention of back pain or spasms. As such, the VA examiner concluded that the Veteran’s current back condition is less likely than not due to in-service back spasms. However, a review of the Veteran’s medical treatment records and her lay statements reveals that she has consistently reported low back pain since her separation from active service. As the examination is not adequate for decision-making purposes, the Veteran must be provided a new VA examination to address the Veteran’s statements that she has suffered from low back pain consistently since her active service. 2. Entitlement to Service Connection for Residuals of Hyperprolactinemia and Premature Ovarian Failure The Veteran contends that she has residuals of hyperprolactinemia and premature ovarian failure that are directly related to her active service. Specifically, the Veteran reported that she had hyperprolactinemia and premature ovarian failure during her active service. Additionally, she reported that since her in-service hyperprolactinemia and premature ovarian failure she has suffered from urine leakage while coughing, sneezing, and/or laughing. The Board notes that the Veteran’s service treatment records reveal that she was diagnosed with hyperprolactinemia and premature ovarian failure. The Veteran was provided a VA examination related to her claim for entitlement to service connection for residuals of hyperprolactinemia and premature ovarian failure in January 2019. The VA examiner noted that the Veteran does not have a current diagnosis of hyperprolactinemia and/or premature ovarian failure. However, the VA examiner did not address whether the Veteran’s reported urine leakage is a residual of her in-service hyperprolactinemia and/or premature ovarian failure. As the examination is not adequate for decision-making purposes, the Veteran must be provided a new VA examination to address whether her reported urine leakage is a residual of her in-service hyperprolactinemia and/or premature ovarian failure. 3. Entitlement to Service Connection for an Eye Disorder, Claimed as Blurred Vision The Veteran contends that she has an eye disorder, claimed as blurred vision, that is directly related to her active service. Specifically, the Veteran testified that she had a sudden onset of blurred vision during her active service that has continued to the present. See, e.g., February 2016 Board hearing transcript. The Veteran was provided a VA examination related to her claim for entitlement to service connection for an eye disorder in January 2019. The VA examiner diagnosed the Veteran with bilateral cortical cataracts and opined that the condition was less likely than not incurred in or caused by the claimed in-service injury event, or illness. As rationale, the VA examiner merely stated that the Veteran’s cataracts are not service related but likely age related. However, the VA examiner did not address the in-service reports of blurred vision or the Veteran’s statements that she has had blurred vision since her active military service. As the examination is not adequate for decision-making purposes, the Veteran must be provided a new VA examination to address whether her bilateral cortical cataracts are related to her active service and her testimony that she has had blurred vision since her active service. 4. Entitlement to a TDIU As noted above, the issue of entitlement to a TDIU has been raised as part and parcel to the Veteran’s claims for higher initial disability ratings. See Rice, 22 Vet. App. 447. As the RO has not yet considered whether the Veteran is entitled to a TDIU, the issue must be remanded to the RO for appropriate development and initial adjudication. The matters are REMANDED for the following action: 1. Send the Veteran a notification letter with respect to her claim for entitlement to a TDIU. The letter should include a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, and a VA Form 21-4142, Authorization and Consent to Release Information to VA, for completion and return to VA. Complete any necessary development as to the claim for entitlement to a TDIU in view of the Veteran’s response to the above notification letter, to include the scheduling of any additional VA examinations deemed warranted. 2. Forward the record and a copy of this remand to the examiner who conducted the January 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a low back disability, to include low back strain, that had its onset during the Veteran’s service or is otherwise etiologically related to the Veteran’s service, to include the service treatment records reflecting that the Veteran suffered from low back pain related to an in-service motor vehicle accident. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the VA examiner must reconcile his/her opinion with the Veteran’s statements that she has suffered from low back pain since her separation from active service. 3. Forward the record and a copy of this remand to the examiner who conducted the January 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Provide a diagnosis for any urine leakage disability demonstrated since service, found on current examination or in the record. (b.) For each urine leakage disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the condition is the result of, or proximately due to, or a manifestation of, in-service hyperprolactinemia and/or premature ovarian failure. Rationale must be provided for the opinion proffered. 4. Forward the record and a copy of this remand to the examiner who conducted the January 2019 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran has an eye disability, to include bilateral cortical cataracts, that had onset during the Veteran’s service or is otherwise etiologically related to the Veteran’s service, to include the Veteran’s reports that she has had blurred vision since her active service. Rationale must be provided for the opinion proffered. 5. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for a low back disability, service connection for residuals of hyperprolactinemia and premature ovarian, and/or service connection for an eye disorder may be granted. If any benefit sought remains denied, furnish the Veteran and her representative with a   supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine 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.