Citation Nr: 20032686 Decision Date: 05/10/20 Archive Date: 05/10/20 DOCKET NO. 18-00 406A DATE: May 10, 2020 ORDER Entitlement to service connection for chronic fatigue syndrome (CFS), to include as secondary to posttraumatic stress disorder (PTSD) and as a qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, is denied. Entitlement to service connection for headaches, to include as secondary to PTSD and as a qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, is denied. Entitlement to an increased rating for PTSD (also claimed as depression), currently evaluated at 70 percent, is denied. REMANDED Issue of entitlement to an increased rating for degenerative arthritis of the spine (claimed as back condition), currently evaluated at 20 percent, is remanded. Issue of entitlement to an increased rating for left knee retropatellar pain syndrome with strain, currently evaluated at 10 percent, is remanded. Issue of entitlement to a total disability rating based on individual unemployability (TDIU) prior to March 6, 2017, is remanded. FINDINGS OF FACT 1. The Veteran does not have a current disability of CFS and the preponderance of the evidence is against finding that the Veteran has a qualifying chronic disability manifested by fatigue due to military service in Southwest Asia. 2. The preponderance of the evidence is against finding that the Veteran’s current headache condition is proximately due to, the result of, or aggravated by his service connected PTSD. 3. The preponderance of the evidence is against finding that the Veteran’s current headache condition was incurred in or otherwise due to service. 4. The preponderance of the evidence is against finding that the Veteran has a qualifying chronic disability manifested by headaches due to military service in Southwest Asia. 5. The preponderance of the evidence shows that the Veteran failed to report, without good cause, for a necessary VA examination scheduled in conjunction with his claim of entitlement to an increased rating for PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for CFS have not been met. 38 U.S.C. §§ 1110, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2019). 2. The criteria for entitlement to service connection for headaches have not been met. 38 U.S.C. §§ 1110, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2019). 3. The criteria for entitlement to a rating higher than 70 percent for PTSD (also claimed as depression) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.655, 4.130, Diagnostic Code 9411 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1990 to March 1999 and August 2002 to August 2003. The Veteran is a Persian Gulf veteran. This appeal to the Board of Veterans’ Appeals (Board) arose from merged appeals of February 2017, March 2017, and January 2018 rating decisions issued by the Department of Veterans Affairs (VA). See March 2017 Notice of Disagreement (NOD); July 2017 Statement of the Case (SOC); January 2018 Substantive Appeal (VA Form 9); March 2018 NOD; March 2018 SOC; August 2018 VA Form 9. The Board notes that the Agency of Original Jurisdiction (AOJ) found the Veteran’s appeal to the Board for his claims of entitlement to increased ratings for degenerative arthritis of the spine and left knee retropatellar pain syndrome with strain to be untimely. January 2018 Correspondence. The Board finds, however, that the January 2018 VA Form 9 is timely because it was filed within one year of the corresponding rating decisions on appeal. See February 2017 Rating decision; March 2017 Rating decision; January 2018 VA Form 9. The issues are, thus, in appellate status and before the Board. The Board also notes that the Veteran submitted a RAMP opt-in election to have his eligible appeals processed under the Appeals Modernization Act (AMA), but the AOJ found his appeals for entitlement to an increased rating for PTSD, entitlement to service connection for CFS, and entitlement to service connection for headaches were ineligible because a substantive appeal for the claims had not been filed at the time. June 2018 RAMP Opt in; August 2018 Appeal notification letter. The Veteran later submitted a timely substantive appeal for the claims under the legacy appeals process. August 2018 VA Form 9. The Board recognizes that additional evidence has been received since the last AOJ adjudication on the claims on appeal, but that evidence is either duplicative or not relevant to the claims being decided in the instant decision. Service Connection Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection is established when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prevail on theory of secondary service connection, there must be evidence of (1) a current disability, (2) a service-connected disability, and (3) a nexus, or link, between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In this case, the evidence shows that Veteran served in the Southwest Asia Theatre of Operations from August 2002 to March 2003 and is, thus, a Persian Gulf veteran. August 2003 DD Form 214. Accordingly, 38 C.F.R. § 3.317 also applies to the Veteran’s claims. Service connection can be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A “qualifying chronic disability” includes an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI) that is defined by a cluster of signs or symptoms, such as CFS, fibromyalgia, and functional gastrointestinal disorders. See 38 C.F.R. § 3.317(a)(2)(i). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. Unlike claims for “direct service connection,” a claim based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 have no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. The term MUCMI is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. Manifestations of undiagnosed illness or MUCMI include fatigue, headaches, and neurological signs or symptoms. 38 C.F.R. § 3.317(b). For purposes of this section, “objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). To determine whether qualifying chronic disability manifested to a degree of 10 percent or more, the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for CFS. The Veteran asserts entitlement to service connection for CFS as related to his service connected PTSD. See December 2017 VA 21 526EZ. As an initial matter, the Board finds that the Veteran has failed to report to an examination scheduled in conjunction with his claim of entitlement to service connection for CFS without good cause. A veteran has a duty to cooperate in the development of his claim. See Wood v. Derwinski, 1 Vet. App. 191 (1991). If a veteran fails to report for an examination scheduled in conjunction with an original compensation claim without good cause, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655(a), (b). Here, the evidence shows that an attempt was made to schedule the Veteran a VA examination for his CFS claim, but it was cancelled due to a lack of response from the Veteran. See December 2017 Subsequent development letter; January 2018 VA examination details screenshot. The Veteran indicated that he did not receive notice of a scheduled appointment, so another attempt to schedule a VA examination was made. See March 2018 NOD; March 2018 Subsequent development letter. Notably, however, the record supports that the Veteran refused to attend the subsequently scheduled VA examination. March 2018 Cancellation of 2507 exam email. The AOJ furnished the Veteran a March 2018 SOC, which informed him that a VA examination was scheduled and that he refused to report. The March 2018 SOC was not returned by the U.S. Postal Service as undeliverable, and the Veteran expressed neither a good cause for his failed appearance nor a willingness to report when he submitted his August 2018 VA Form 9. As this is an original compensation claim and the Veteran failed to report to a necessary examination scheduled for his CFS claim without good cause, his claim will be based on the available evidence of record. After careful and thorough review of the evidence, the Board finds that the preponderance of the evidence is against finding that entitlement service connection for CFS is warranted. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See, e.g., Degmetich v. Brown, 104 F.3d 1328 (1997). Congress has specifically limited entitlement to service connection for a disease or injury where such instances have resulted in a disability. 38 U.S.C. §§ 110, 1131. Hence, where the evidence does not support a finding of a current disability of CFS upon which to predicate the grant of service connection, there can be no valid claim for this benefit. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the medical evidence of record shows no treatment or diagnosis for CFS. As for the lay evidence, the Veteran provided no explanation about why he believes he has CFS, what symptoms he believes is associated with his CFS, nor if he has functional limitations resulting from CFS. See December 2017 VA 21 526EZ; March 2018 NOD. The Board considered the Veteran’s complaints of “fatigue” to his treatment providers, but his fatigue was assessed as part of his thyroid, colitis, or depression/anxiety conditions with no mention of CFS. See June 2014 VA treatment evidence; November 2017 VA treatment evidence; January 2018 VA treatment evidence. Moreover, while the Veteran is competent to report having experienced symptoms such as fatigue, the causation falls outside of the realm of knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, supra. The Veteran’s statements that he has CFS, thus, have no probative value. Id. As there is no probative evidence of CFS, nor evidence of symptoms related to his claim of CFS that amount to a disability that functionally impairs the Veteran per Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the evidence is highly probative evidence against the Veteran’s claim of a current CFS disability. The Board also considered whether entitlement to service connection for CFS is warranted under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as a disability due to an undiagnosed illness or MUCMI occurring in Persian Gulf veterans. As discussed above, there is no evidence supporting a CFS diagnosis to be considered for entitlement to service connection as a MUCMI. The Veteran’s complaints of fatigue are attributed to known clinical diagnoses, and there is no evidence of another symptom associated with the Veteran’s CFS claim for consideration as an undiagnosed illness. Based on the probative evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran has a current disability of CFS or that he has a qualifying chronic disability manifested by fatigue due to military service in Southwest Asia. Accordingly, the Board finds that service connection for CFS is not warranted. 2. Entitlement to service connection for headaches. The Veteran asserts entitlement to service connection for headaches as related to his service connected PTSD. December 2017 VA 21 526EZ. As with his claim of entitlement to service connection for CFS, the evidence shows the Veteran also failed to report to an examination scheduled in conjunction with his claim of entitlement to service connection for headaches without good cause. A veteran has a duty to cooperate in the development of his claim and if a veteran fails to report for an examination scheduled in conjunction with an original compensation claim without good cause, the claim shall be rated based on the evidence of record. See Wood, 1 Vet. App. 191 (1991); 38 C.F.R. § 3.655(a), (b). The first attempt to schedule the Veteran for a VA examination for headaches was cancelled due to a lack of response from the Veteran. See December 2017 Subsequent development letter; January 2018 VA examination details screenshot. The Veteran indicated that he did not receive notice of a scheduled appointment, so another attempt to schedule a VA examination was made. See March 2018 NOD; March 2018 Subsequent development letter. The record supports that the Veteran refused to attend the subsequently scheduled VA examination. March 2018 Cancellation of 2507 exam email. The AOJ furnished the Veteran a March 2018 SOC, which informed him that a VA examination was scheduled and that he refused to report. The March 2018 SOC was not returned by the U.S. Postal Service as undeliverable, and the Veteran expressed neither a good cause for his failed appearance nor a willingness to report when he submitted his August 2018 VA Form 9. As the Veteran failed to report to a necessary examination scheduled for his headaches claim without good cause, his claim will be based on the available evidence of record. After careful and thorough consideration of the evidence, the Board finds that the preponderance of the evidence is against finding that service connection for headaches is warranted. The medical evidence shows no treatment or diagnosis for a headache condition. However, the Veteran asserts to having headaches. See December 2017 VA 21 526EZ; March 2018 NOD. The Veteran is competent to identify having headaches as it is a symptom that he personally experiences and can report. See Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). While the evidence does not show that the Veteran has complained of headaches to his treatment providers, the Board finds that the evidence is in at least relative equipoise in finding that he has a current headache condition. The evidence shows that the Veteran is currently service connected for PTSD. See January 2018 Rating decision. However, the Board finds that there is no evidence supporting the Veteran’s current headaches are proximately due to, the result of, or aggravated by his PTSD. As noted above, there is no medical evidence showing treatment for a headache condition. The Veteran has only asserted to having headaches and has not described his symptoms or why he believes they are secondary to his PTSD. The Board also considered a December 2016 VA examination for PTSD, which shows that the Veteran reported symptoms that include trouble sleeping, depressed mood, hypervigilance, anxiety, memory loss, and anger associated with his PTSD, but did not mention having headaches. December 2016 VA examination. Based on the overall lay and medical evidence, the Board finds that the preponderance of the evidence is against finding that the Veteran’s current headache condition is proximately due to, the result of, or aggravated by to his service connected PTSD. The Board also considered whether the evidence supports that the Veteran’s headaches were incurred in or otherwise due to service on a direct basis. Service treatment records show that the Veteran reported constant headaches with trouble focusing due to a head injury. April 1993 Service treatment record. The Veteran reported continued headaches a few days later. See April 1993 Service treatment record. However, several subsequent Reports of Medical Examination and Reports of Medical History show no mention of headaches and, instead, that the Veteran specifically denied having headaches. See, e.g., September 1993 Report of Medical Examination; September 1993 Report of Medical History; August 1997 Report of Medical Examination; August 1997 Report of Medical History; February 1999 Report of Medical Examination; February 1999 Report of Medical History. During an examination to establish medical care after separation, the Veteran denied having cognitive slowing, headache, or balance difficulty since service. January 2009 VA treatment evidence. In addition, the Veteran has not asserted with his claim that his headaches were incurred during service. The Board, thus, finds that the preponderance of the evidence is against finding that the Veteran’s current headache condition was incurred in or otherwise due to service on a direct basis. Lastly, the Board considered whether entitlement to service connection for headaches is warranted under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 as a disability due to an undiagnosed illness or MUCMI occurring in Persian Gulf veterans. The medical evidence shows no treatment or complaints of headaches and the Veteran has provided no statement as to whether his headaches have existed for 6 months or more to be considered chronic under 38 C.F.R. § 3.317(a)(4). The evidence also does not support that the Veteran’s headaches manifested to a degree of 10 percent or more as required under 38 C.F.R. § 3.317(a)(1)(i). The evidence does not show that his headaches have manifested with at least characteristic prostrating attacks averaging one in 2 months over a several month period to warrant a 10 percent rating. See 38 C.F.R. §§ 3.317(a)(5), 4.125a, Diagnostic Code 8100. The Board, thus, finds that the preponderance of the evidence is against finding that the Veteran’s headaches are a qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. Accordingly, the Board finds that entitlement to service connection for headaches, to include as secondary to PTSD or as a qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, is not warranted. Increased Rating Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. See 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Board has considered the entire record, but only the evidence pertinent to the rating criteria and current disability will be discussed. See Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to an increased rating for PTSD (also claimed as depression), currently evaluated at 70 percent. In December 2017, the Veteran submitted a claim of entitlement to an increased rating for PTSD. December 2017 VA Form 21 526EZ. The Veteran contends that his PTSD warrants an “80%” rating. March 2018 NOD. The Veteran’s PTSD is currently evaluated under Diagnostic Code 9411 and rated as 70 percent disabling. See January 2018 Rating decision. Under Diagnostic Code 9411, a 70 percent rating is warranted for a mental disorder that manifests with occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The next higher, and highest rating, of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. As an initial matter, the Board notes that the prior August 2017 rating decision that denied the Veteran’s claim for a rating in excess of 70 for PTSD is a finally adjudicated claim. The Veteran did not file for an appeal of the August 2017 rating decision nor requested reopening his prior claim, but, instead, filed a new claim for entitlement to an increased rating. See December 2017 VA Form 21 526EZ. Additional evidence was associated with the claims file within a year of the August 2017 rating decision, but, as discussed in further detail below that evidence does not affect the finality of the rating decision under 38 C.F.R. § 3.156(b) because it is not new and material. While the additional evidence is new, it does not relate to unestablished facts necessary to substantiate a rating higher than 70 percent for PTSD. As the August 2017 rating decision was not appealed and there was no new and material evidence associated with the claim within a year of notice of the decision, the rating decision became final. For the instant appeal, the question for the Board is whether the Veteran’s claim of entitlement to an increased rating for PTSD must be denied due to failure to report for a scheduled VA examination. The evidence shows that the Veteran failed to report to two VA examinations scheduled in conjunction with his claim of entitlement to an increased rating for PTSD. A veteran has a duty to cooperate in the development of his claim. See Wood, 1 Vet. App. 191 (1991). For a claim of entitlement to an increased rating, if entitlement to a benefit cannot be established without a current VA examination and a veteran fails to report for an examination scheduled in conjunction with a claim for an increase rating without good cause, the claim shall be denied. See 38 C.F.R. § 3.655(a), (b). The Board must consider (1) whether an examination was necessary to establish entitlement to the benefit sought and, if so, (2) whether the Veteran lacked good cause to miss the scheduled examination. See Turk v. Peake, 21 Vet. App. 565, 569 (2008). The medical evidence since the August 2017 rating decision shows recent treatment for depression, sleep problems, and racing thoughts, but that the mental status examination findings generally noted the Veteran as alert, oriented, and cooperative. February 2018 VA treatment evidence; See, e.g., September 2016 VA treatment evidence; June 2017 VA treatment evidence, November 2017 VA treatment evidence. There are no lay statements about the Veteran’s PTSD symptoms since the last final August 2017 rating decision. The Veteran declined a referral for mental health treatment, so the claims file contains no comprehensive mental health assessment since August 2017. Id. In addition, the Veteran has provided no statements about his mental health symptoms since August 2017. The Board considered the Veteran’s contention that he is entitled to an “80%” rating, but, while the Veteran is competent to report his mental health symptoms, he is not competent to state whether his symptoms warrant a specific rating under the schedule for rating disabilities. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed Cir. 2006); Jandreau, 492 F.3d at 1376-77. For example, the General Rating Formula for Mental Disorders does not have an 80 percent rating available. See 38 C.F.R. § 4.130. The Board, thus, finds that a VA examination was necessary to determine whether the Veteran’s PTSD warrants an increased rating. As to whether there was good cause for the Veteran’s failure to show for the scheduled VA examinations, the evidence shows that the first attempt to schedule the Veteran for a VA examination for PTSD was cancelled due to a lack of response from the Veteran. See December 2017 Subsequent development letter; January 2018 VA examination details screenshot. The Veteran indicated that he did not receive notice of a scheduled appointment, so another attempt to schedule a VA examination was made. See March 2018 NOD; March 2018 Subsequent development letter. The evidence indicates that the Veteran refused to attend the subsequently scheduled VA examination. March 2018 Cancellation of 2507 exam email. The record reflects the AOJ furnished the Veteran a March 2018 SOC, which informed him that a VA examination was scheduled and that he had refused to report. The March 2018 SOC was not returned by the U.S. Postal Service as undeliverable, and the Veteran expressed neither a good cause for his failed appearance nor a willingness to report for the subsequent examination when he submitted his August 2018 VA Form 9. Based on this evidence, the Board finds that, while there was good cause for failure to report to the first scheduled VA examination, the Veteran failed to report to the subsequently scheduled VA examination for his PTSD claim without good cause. The Board notes that even if the Veteran’s claim for an increased rating for PTSD was evaluated based on the available evidence of record, the preponderance of the evidence would be against finding entitlement to a rating in excess of 70 percent. The evidence of depressed mood, problems sleeping, and racing thought would not support total occupational and social impairment. 38 C.F.R. § 4.130, Diagnostic Code 9411; February 2018 VA treatment evidence. The evidence does not support symptoms such as gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger to himself or others, or disorientation to time or place. Rather, the Veteran was noted to have normal or sad mood, alert and oriented, and to be cooperative during his medical treatment visits. June 2017 VA treatment evidence; November 2017 VA treatment evidence; February 2018 VA treatment evidence. As the Veteran’s PTSD claim is a claim for an increase and he failed to report for scheduled VA examination necessary to established entitlement to an increase without good cause, the Board finds that the Veteran’s claim must be denied. REASONS FOR REMAND 1. Issue of entitlement to an increased rating for degenerative arthritis of the spine (claimed as back condition), currently evaluated at 20 percent is remanded. 2. Issue of entitlement to an increased rating for left knee retropatellar pain syndrome with strain, currently evaluated at 10 percent. The Board cannot make a fully informed decision on the issues of entitlement to increased ratings for degenerative arthritis of the spine or left knee retropatellar pain syndrome with strain because further development is needed. While the record contains VA examinations regarding the Veteran’s degenerative arthritis of the spine and left knee retropatellar pain syndrome with strain during the period on appeal, the examinations do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The Veteran was afforded December 2016 and February 2017 VA examinations for his degenerative arthritis of the spine. The Veteran reported a history of flare-ups with his back conditon during both examinations, but the examiner stated that an opinion on additional functional restrictions during a flare-up could not be provided without resort to speculation. December 2016 VA examination for back condition; February 2017 VA examination for back conditions. The examiner did not indicate in either examination report that the speculation was due to lack of knowledge within the medical community and, instead, stated that it would be speculative to opine on functional limits “beyond the data resulted with repetitive ROM testing in his report.” December 2016 VA examination for back condition; February 2017 VA examination for back conditions. Likewise, the Veteran reported having a history of flare-ups with his left knee during the December 2016 VA examination for knee and lower leg conditions, but the examiner stated that an opinion on additional functional restrictions during a flare-up could not be provided without resort to speculation without indicating that the speculation was due to lack of knowledge within the medical community. Here, the VA examiner also appears to have limited her opinion to the observed ROM findings during testing without considering whether estimated knee range of motion limits during a flare-up could be made based on the Veteran’s lay statements. See December 2016 VA examination for knee and lower leg conditions. The Board, therefore, finds that addendum opinions from a VA examiner(s) are needed for the Veteran’s degenerative arthritis of the spine and left knee retropatellar pain syndrome with strain. The Board recognizes that the AOJ attempted to schedule the Veteran for subsequent VA examinations for his lumbar spine and left knee conditions in July 2017 and in June 2019. July 2017 VA Form 21 2507a; June 2019 Exam Request. However, the Veteran reported being “too sick” to attend the July 2017 VA examinations as good cause for his failure to report. July 2017 Correspondence. The claims file only indicates that the Veteran was “unavailable” to attend the June 2019 VA examinations, so it is unclear if there was good cause. June 2019 Exam requests. 3. Issue of entitlement to a TDIU for the period prior to March 6, 2017. During the pendency of the appeal, the Veteran asserted that his back, knee, and PTSD disabilities prevents him from working. See March 2017 NOD; January 2018 VA Form 9; August 2018 VA Form 9. The Board finds that a derivative “Rice” TDIU claim is reasonably raised by the Veteran’s lay statements as part and parcel of the Veteran’s claims for increased ratings. See Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009) (when entitlement to TDIU is raised during the administrative appeal of the increased rating or initial rating assigned for the underlying disability or disabilities, it is a part of the claim for benefits for that disability or disabilities). The Board notes that the Veteran filed a traditional claim for TDIU that was granted effective March 6, 2017, and, accordingly, only the period prior to March 6, 2017, is relevant for consideration. However, because a decision on the remanded issues of entitlement to increased ratings for degenerative athritis of the spine and left knee retropatellar pain syndrome with strain could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. For example, because the Veteran’s entitlement to a 70 percent rating for PTSD is effective March 6, 2017, it may not be considered in determining the Veteran’s entitlement to to a TDIU prior to March 6, 2017. The Veteran’s current ratings for his service connected disabilities prior to March 6, 2017, including his degenerative athritis of the spine and left knee retropatellar pain syndrome with strain, thus, do not qualify for a TDIDU because the Veteran does not have one disability ratable at 40 percent or more, nor a combined disability rating of 70 percent or more. See 38 C.F.R. § 4.16(a). A remand of the claim for a Rice TDIU is, thus, required as inextricably intertwined. The matters are REMANDED for the following action: 1. Obtain addendum opinions from an appropriate medical professional to determine the severity of the Veteran’s service connected degenerative arthritis of the spine and left knee retropatellar pain syndrome with strain. If possible, obtain the opinion from the same medical professional who provided the December 2016 and February 2017 VA examination reports for his spine and left knee disabilities. If the medical professional determines that it is necessary, schedule the Veteran for VA examination(s) (which may include the scheduling of a virtual video or teleconference examination, if feasible) to determine the current severity of his service connected degenerative arthritis of the spine or left knee retropatellar pain syndrome with strain (or a telehealth interview, review of the record, etc., if an in person examination is not feasible). (a) Based on the particulars of the Veteran’s history and the clinical data, the examiner should provide a full description of each disability and report all signs and symptoms necessary for evaluating the Veteran’s degenerative arthritis of the spine and left knee retropatellar pain syndrome with strain disabilities. (b) The examiner must identify the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing during the entire period on appeal. 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). (c) The examiner must also attempt to elicit information and/or identify 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 clinical 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). 2. Review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above if deemed warranted by the AOJ, and re-adjudicate the claims, including entitlement to a Rice TDIU prior to March 6, 2017. If the AOJ deems it necessary, consider referring the TDIU claim to the Director of Compensation Service for consideration on an extraschedular basis. 3. If a claim is denied, supply the Veteran and his representative, if any, with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.