Citation Nr: 20032884 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 17-07 391 DATE: May 12, 2020 ORDER Entitlement to a separate, initial 10 percent rating for limited range of flexion in the service-connected left knee is GRANTED. Entitlement to a separate, initial 10 percent rating for limited range of extension in the service-connected left knee is GRANTED. Entitlement to a separate, initial 10 percent rating for lateral instability in the service-connected left knee is GRANTED. REMANDED Entitlement to service connection for loss of taste, secondary to the residuals of Bell’s Palsy, is REMANDED. Entitlement to service connection for lagophthalmus and photophobia, secondary to the service-connected residuals of Bell’s Palsy, is REMANDED. FINDINGS OF FACT 1. During the appellate period, the Veteran’s service-connected left knee disability was manifested by 45 degrees of flexion. 2. During the appellate period, the Veteran’s service-connected left knee disability was manifested by 10 degrees of extension. 3. During the appellate period, the Veteran’s service-connected left knee disability was manifested by slight lateral instability. 4. During the appellate period, the evidence reflects that the Veteran did not demonstrate left knee ankylosis or a meniscal condition. CONCLUSIONS OF LAW 1. The criteria for a separate, initial rating of 10 percent for limited flexion of the service-connected left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2019). 2. The criteria for a separate, initial rating of 10 percent for limited extension of the service-connected left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2019). 3. The criteria for a separate, initial rating of 10 percent for left knee lateral instability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2019).   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army form February 2007 to February 2011. Importantly, the Veteran’s certificate of discharge from active duty (DD214) reveals that she was a surgical nurse (66H) in the United States Army. INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany her service-connected left knee disability. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). 1. Entitlement to three separate, initial 10 percent ratings for a service-connected left knee disability is granted. In September 2011, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated an entitlement claim for a left knee condition. In September 2012, the agency of original jurisdiction (AOJ) granted service connection and assigned a non-compensable rating based on, “X-ray evidence of arthritis without evidence of limited or painful motion.” The AOJ assigned the effective date as the day after the Veteran separated from active duty service. In September 2013, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran posited that, “I have suffered from left knee pain since military service. I am not sure why I only received a 0% rating for this condition. This condition bothered at the time of medical examination and still bothers me today. Specifically, it intermittently hurts with movement. I possibly did not correctly convey pain during my examination, but my left knee still causes pain today. . . . . My knee hurts with movement. I have arthritis in my left knee and have decreased range of motion. Please consider the additional evidence demonstrating painful and decreased range of motion.” Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying scheduler criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 should only be considered in conjunction with the Diagnostic Codes (DCs) predicated on limitation of motion. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, including knee joints, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran has been in receipt of a noncompensable evaluation under DC 5260-5003 since the day after separation from the United States Army, February 15, 2011. See 38 C.F.R. § 4.71 (a). In addition to the service-connection compensation available under DC 5060, this claim requires consideration of the other possibly applicable Diagnostic Codes. Under DC 5260, degenerative joint disease shall be rated based on limitation of motion of the right knee, as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. 38 C.F.R. § 4.71a, DC 5260. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated based on limitation of motion under appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. If there is limitation of motion but it is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion—to be combined, not added. If there is no limitation of motion, a 10 percent rating applies if there is X-ray evidence that two or more major joints or two or more minor joint groups are involved. A 20 percent rating applies if there is X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 U.S.C. § 4 .71a, DC 5003. For purposes of rating disability from arthritis, the major joints are the shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45. Although “incapacitating exacerbations” is not defined under DC 5003, the Board analogizes it to “incapacitating episodes,” which is defined in the IVDS Formula at Note (1) as “a period of acute signs and symptoms . . . that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, DC 5003, IVDS Formula at Note (1). Under DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71 (a), DC 5257. DC 5258 assigns a 20 percent evaluation for dislocated semilunar cartilage (meniscus) with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71 (a), DC 5258. Additionally, DC 5259 assigns a 10 percent rating for removal of semilunar cartilage, symptomatic. 38 C.F.R. § 4.71 (a), DC 5259. Under DC 5260, which provides disability evaluations based on limitation of flexion, a noncompensable evaluation is warranted when knee flexion is limited to 60 degrees; a 10 percent evaluation is warranted when flexion is limited to 45 degrees; a 20 percent evaluation is warranted when flexion is limited to 30 degrees; and a 30 percent evaluation is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71 (a), DC 5260. Under DC 5261, a 10 percent evaluation is warranted when extension is limited to 10 degrees, a 20 percent evaluation is warranted when extension is limited to 15 degrees, a 30 percent evaluation is warranted when extension is limited to 20 degrees, a 40 percent evaluation is warranted when extension is limited to 30 degrees, and a 50 percent evaluation is warranted when extension is limited to 45 degrees. 38 C.F.R. § 4.71 (a), DC 5261. Normal range of motion of the knee is 0 to 140 degrees of extension to flexion. 38 C.F.R. § 4.71 (a), Plate II. VAOPGCPREC 23-97 provides that a Veteran may be assigned separate ratings for arthritis with limitation of motion under DC 5260 or 5261, and for instability or subluxation under DC 5257. See VAOPGCPREC 23-97 (July 1, 1997). In VAOPGCPREC 9-98, VA General Counsel held that if a veteran has a disability rating under DC 5257 for instability or subluxation of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be assigned based on painful motion under 38 C.F.R. § 4.59. Additionally, the VA General Counsel issued an opinion holding that “separate ratings may be assigned under DC 5260 and DC 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg.” See VAOPGCPREC 9-2004 (September 17, 2004). In August 2012, the Veteran underwent a VA examination that considered the severity of the now-service-connected left knee disability. At that time, the VA examiner concluded that the Veteran did not have / or ever had a left knee disability. At that time, the Veteran relayed that, “I fell and injured ankle and noticed knee pain at same time.” For flare-ups, the Veteran relayed that, (w)hen I increase activity like run or bike, have to stop being as active and it settles.” The VA examiner reported 140 degrees (or greater) flexion and 0 degrees extension with no objective evidence of painful motion. At that time, there was no demonstrated change in range of motion (ROM) with repetitive use. The VA examiner relayed that there was no functional loss and/or functional impairment of the left knee and lower leg. The Veteran demonstrated 5/5 strength in flexion and extension. The VA examiner reported “normal” lateral instability. The VA examiner noted that the Veteran had never had a left knee meniscal condition. The VA examiner noted that there was no history of patellar subluxation/dislocation. The VA examiner noted that the Veteran does not have or has ever had “shin splints,” stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The VA examiner reported that the Veteran’s left knee and/or lower leg did not impact her ability to work. In March 2014, a letter from the Veteran’s sister was associated with the claims file. Therein, the sibling posits that, “I have personally witnessed (the Veteran’s) knee swell up following activities such as walking. I have also seen her grimace in pain during such activities. Her range of motion is limited. This is especially apparent when she bends over or get in her car. Last summer while walking on a trail her knee gave out on her a few times. These occurrences are common. This instability frustrated her and caused her to be guarded.” In February 2017, the Veteran submitted a VA Form 9. Therein, the Veteran posited that, “I am not sure why I only received a 0% rating for this condition. This condition bothered me on the day of my medical examination and still bothers me today. Specifically, it hurts when moving it. Although I didn’t scream in pain, I certainly winced during my examination. I’m not sure what is needed to convey pain, but my left knee did hurt during the examination as it still does today. . . . My knee hurts with movement. . . . I have arthritis in my left knee and have deceased range of motion. Please consider the additional evidence demonstrating painful and decreased range of motion. I request 2 separate 10% evaluations for pain and arthritis with decreased range of motion.” In July 2019, a knee and lower leg conditions DBQ was associated with the claims file. The examiner noted February 2011 diagnoses for left knee strain, osteoarthritis, and instability. The Veteran reported that, “her left knee flares up with multiple movements/exercise and causes discernible pain/discomfort. Problems persist today.” For flare-ups, the Veteran reported that, “discomfort, reduced motion, tenderness, tough to walk uneven surfaces or go for brisk walk when in active flareup. Long walks cause pain and ached with little exercise.” For functional loss, the examiner reported that, “can’t go on long walks or runs anymore. During flareup it can be tough to get in/out of vehicle or other low seats. Left (knee) leg gives on me and seems unstable at times. She has mentioned that she has fallen a few times with recent medical history.” For initial ROM, the Veteran demonstrated 115 degrees of flexion and 5 degrees extension. The examiner noted no change in left knee ROM after repetitive testing. The examiner noted that the Veteran demonstrated objective pain on weight-bearing and during active, passive and/or repetitive testing. The examiner noted localized tenderness or pain on palpation, noting medial and lateral compartment pain. For functional loss, the examiner noted pain on movement and instability of station. The examiner noted that pain, weakness, fatigability, or incoordination, which limited flexion to 45 degrees and extension to 10 degrees. The examiner noted that functional loss during flare-ups resulted in “getting out of seats and getting up from sitting pain/discomfort. Instability of station. Aching. Unsteadiness during flareups. Struggle to maintain healthy lifestyle w/ flareups.” The examiner noted 5/5 strength testing in flexion and extension with no observed muscle atrophy. The examiner noted that the Veteran had never had a left knee meniscal condition. The Veteran did not demonstrate ankylosis. The examiner noted a slight history of lateral instability, noting that lateral instability tested at 0-5 millimeters. The examiner noted that the Veteran does not have or has ever had “shin splints,” stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner noted that the Veteran occasionally utilized a brace. The examiner noted that, “mild degenerative changes to medial compartment noted on xray on C&P exam on 8/23/2012.” The observed left knee crepitus, noting that “slight grinding palpitated with ROM, left knee pain with squatting, sitting to standing noted, the valgus test which checks medial ligaments was painful with examination.” The examiner noted that, “active work will be limited, especially during flareup. Workplace accommodations might be needed for certain expected/routine movements. Lowering/raising from seat difficult in certain situations. Ambulation uneven terrain might present challenges for this veteran.” The examiner remarked that, “the Veteran complains of difficulty in maintaining a healthy lifestyle and exercise due to pain and repeated flare ups. X-ray results 8/22/2012 verify a medical abnormality with degenerative changes in the medial compartment of the knee. Veteran continues to self-treat with motrin for pain. Veteran has to avoid certain activities and family events due to recurrent flare up of left knee. I find this left knee medical condition worsening over time.” After review of the claims file, the Board finds that separate, initial evaluations for the Veteran’s service-connected left knee disability are warranted. The Board observes that the Veteran, and her sibling, have supplied competent and credible statements regarding the severity of the service-connected left knee disability during the appellate period. Moreover, with consideration of the Deluca factors such as pain, weakness, fatigability, or incoordination significantly limiting functional ability during flare-ups or with repeated use of the joint, the July 2019 examiner estimated that left knee flexion would decrease to 45 degrees and extension would decrease to 10 degrees, and slight lateral instability. The examiner also noted February 2011 diagnoses for left knee strain, osteoarthritis, and instability. The Board observes that the August 2012 and July 2019 examiners noted that the Veteran did not demonstrate a left knee meniscal condition or ankylosis; therefore DCs 5258 and 5256 are not for application. Consequently, the Board concludes that separate, initial ratings of 10 percent under DC 5260, 10 percent under DC 5261, and 10 percent under DC 5257 are warranted by the evidence. See 38 C.F.R. § 4.71 (a). A rating greater than 10 percent is not warranted under DC 5260 as the record does not show, even with consideration of additional limitations during periods of flare up, does not show limited flexion to 30 degrees or less. Likewise, a rating greater than 10 percent is warranted under DC 5261 as the record, even with consideration of additional limitations during period of flare up, does not show limited extension to 20 degrees or greater. Likewise, an initial disability evaluation greater than 10 percent for instability under DC 5257 is not warranted as the record does not show moderate or severe recurrent subluxation or lateral instability. Ultimately, the preponderance of the evidence favors the Veteran’s claim for initial increased ratings for the service-connected left knee disability. Accordingly, this increased disability rating claim must be granted. The Board notes that the Veteran and her attorney have not 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 Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to her country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing her claims prior to final adjudication. 2. Entitlement to service connection for loss of taste, secondary to the residuals of Bell’s Palsy, is remanded. In September 2011, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated an entitlement claim for loss of taste. In September 2011, the Veteran’s treatment notations form Southeastern Neurology were associated with the claims file. Therein, it was reported that, “(s)he says she was eating her sandwich and noticed that she could not taste on the left side of her tongue. She noticed that she was starting to have some weakness of the left side of the face and then the entire face was involved. She cannot completely close her eye.” In August 2012, the Veteran underwent a VA examination that considered the nature and etiology of any current cranial nerve conditions. The VA examiner noted a current diagnosis for the residuals of Bell’s Palsy left. For medical history, the VA examiner relayed that, “the veteran developed left Bell’s Palsy in Sept 2011 when she was in her last trimester of pregnancy. She has recovered except for mild residual weakness and occasional left facial paresthesias and a dull ache. She no longer has ear pain and her taste is normal.” In August 2012, a VA examiner generated a General Medical – Compensation Disability Benefits Questionnaire (DBQ). Import to this analysis, the VA examiner noted that, “Loss of taste – RESOLVED – DBQ NOT INDICATED.” In September 2013, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran posited that, “since the onset of bell’s palsy, I cannot taste food like I once did. Please consider the additional evidence demonstrating loss of taste secondary to my service-connected bell’s palsy. Please consider the additional evidence demonstrating this. I request a 10% evaluation for loss of taste secondary to bell’s palsy.” In February 2017, the Veteran submitted a VA Form 9. Therein, the Veteran posited that, “since the onset of bell’s palsy, I cannot taste or smell food like I once did. Please consider the additional evidence demonstrating loss of taste and smell secondary to my service-connected bell’s palsy. . . . I request 2 separate 10% evaluations for loss of taste and loss of smell secondary to bell’s palsy.” Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See 38 C.F.R. § 3.159 (a)(2). The Board has thoroughly reviewed the entire claims file; nevertheless, the Board does not identify the “additional evidence” posited by the Veteran, which addresses the claimed loss of taste. However, as a former Army surgical nurse, the Veteran is competent to identify the loss taste. See Jandreau v. Nicholson, 492 F.3d 1372, 1733 (Fed. Cir. 2007). Consequently, the AOJ should schedule the Veteran for a VA examination that addresses the nature and etiology of the competently identified loss of taste. 3. Entitlement to service connection for lagophthalmus and photophobia, secondary to the service-connected residuals of Bell’s Palsy, is remanded. In September 2011, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated an entitlement claim for lagophthalmus and photophobia. In August 2012, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured eye conditions. The VA examiner noted diagnoses for intermittent myokymia, lagophthalmos (resolved), and photophobia. The VA examiner noted that the Veteran was not receiving any current treatment for the noted diagnoses. The VA examiner noted that the Veteran’s left sided bell’s palsy with lagophthalmus resolved in March 2012. The VA examiner noted that the Veteran’s photophobia resolved after bell’s palsy resolved. The VA examiner reported that the Veteran had not had any incapacitating episodes attributable to any eye condition in the prior 12-month period. In September 2013, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran posited that, “I experience this frequently throughout the year. When the onset occurs, the condition is debilitating, requiring drastic attention to my eyes. As this is a common problem associated with my bell’s palsy, at a minimum, please consider granting this condition a 10% rating as it can have a profound effect on my quality of life.” In February 2017, the Veteran submitted a VA Form 9. Therein, the Veteran posited that, “I experience this occasionally throughout the year. When the onset occurs, the condition is debilitating requires drastic treatment of my eyes. I literally have to tape my eyelids shut. Additionally, this has a negative effect to light sensitivity as well. . . . As this is a common problem associated with my bell’s palsy, at a minimum, please consider granting this condition at 10% rating as it can have a profound effect on my quality of life.” Again, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See 38 C.F.R. § 3.159 (a)(2). The Board has thoroughly reviewed the entire claims file; nevertheless, the Board does not identify “additional evidence” that addresses the Veteran’s claimed lagophthalmus and photophobia. However, as a former surgical nurse, the Veteran is competent to identify lagophthalmus and photophobia. See Jandreau, 492 F.3d at 1733. Consequently, the AOJ should schedule the Veteran for a VA examination that addresses the nature and etiology of the competently identified lagophthalmus and photophobia. Consequently, the matters are REMANDED to the agency of original jurisdiction (AOJ) for the following action: 1. Contact the Veteran, and, with her assistance, identify any outstanding records of pertinent medical treatment from VA, Federal, or private health care providers. With the Veteran’s assistance obtain copies of any pertinent records and add them to the claims file. Follow the procedures for obtaining the records set forth by 38 C.F.R. § 3.159 (c) (2017). If VA attempts to obtain any outstanding records which are unavailable, the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). 2. The Veteran should be scheduled for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) with the appropriate physician, to determine the nature and etiology of any currently endured loss of taste, lagophthalmus, and photophobia. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following question: Is it at least as likely as not (i.e. a 50 percent probability or greater) that any loss of taste, lagophthalmus, or photophobia currently endured by the Veteran was (i) caused by or (ii) aggravated by the Veteran’s service- connected residuals of Bell’s Palsy? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that she had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of her loss of taste, lagophthalmus, and photophobia. 3. After completing any other development that may be warranted, the AOJ should readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and her attorney must be given a supplemental statement of the case (SSOC) and a reasonable opportunity to respond before the record is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, Associate 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.