Citation Nr: 20042880 Decision Date: 06/24/20 Archive Date: 06/24/20 DOCKET NO. 18-03 308 DATE: June 24, 2020 ORDER Whether new and material evidence has been received to reopen the claim for entitlement to service connection for numbness and pain in the right upper extremity is dismissed. Entitlement to service connection for a hysterectomy is dismissed. Entitlement to service connection for a dental condition is dismissed. Entitlement to service connection for a chest condition is dismissed. New and material evidence having been received, the appeal to reopen the claim for entitlement to service connection for numbness and pain in the left upper extremity (hereafter referred to as a “left upper extremity condition”) is granted. Entitlement to service connection for a left upper extremity condition is denied. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected hypertension, is denied. Entitlement to service connection for a low back disability, to include as secondary to service-connected right knee condition, is denied. Entitlement to service connection for a preexisting bilateral foot disability is denied. From October 7, 2014, to August 15, 2017, entitlement to a 70 percent disability rating, and no higher, for service-connected persistent depressive disorder with anxious distress and alcohol use disorder in sustained remission (hereafter referred to as a "psychiatric condition") is granted. From August 16, 2017, to November 5, 2019, entitlement to a disability rating in excess of 30 percent for service-connected psychiatric condition is denied. REMAND From November 6, 2019, entitlement to a disability rating in excess of 30 percent for service-connected psychiatric disability is remanded. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ, to include as secondary to service-connected hypertension or psychiatric condition, is remanded. FINDINGS OF FACT 1. At her November 2019 hearing, prior to the promulgation of a decision on the appeal, the Veteran withdrew her appeal of the issue of whether new and material evidence has been received to reopen the claim for entitlement to service connection for numbness and pain in the right upper extremity. The withdrawal was explicit, unambiguous, and completed with a full understanding of the consequences of her actions. 2. At her November 2019 hearing, prior to the promulgation of a decision on the appeal, the Veteran withdrew her appeal of the issue of entitlement to service connection for a hysterectomy. The withdrawal was explicit, unambiguous, and completed with a full understanding of the consequences of her actions. 3. At her November 2019 hearing, prior to the promulgation of a decision on the appeal, the Veteran withdrew her appeal of the issue of entitlement to service connection for a dental condition. The withdrawal was explicit, unambiguous, and completed with a full understanding of the consequences of her actions. 4. The evidence associated with the claims file since the December 2002 final denial includes evidence that relates to an unestablished fact necessary to substantiate the claim, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim for service connection for a left upper extremity condition. 5. The evidence of record is against finding that the Veteran has had a left upper extremity condition at any time during, or approximate to, the pendency of the claim. 6. The evidence of record is against finding that the Veteran’s OSA occurred in, or is the result of, her period of active duty service. 7. The evidence of record is against finding that the Veteran’s low back disability occurred in, or is the result of, her period of active duty service. 8. The Veteran’s bilateral foot condition preexisted her period of active duty service, and she has not shown that such period of service aggravated, beyond natural progression, that preexisting condition. 9. From October 7, 2014, to August 15, 2017, the Veteran’s service-connected psychiatric condition more closely approximates occupational and social impairment with deficiencies in most areas. 10. From August 16, 2017, to November 5, 2019, the Veteran’s service-connected psychiatric condition more closely approximates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for whether new and material evidence has been received to reopen the claim for entitlement to service connection for numbness and pain in the right upper extremity have been met. 38 U.S.C. § 7105(d); 38 C.F.R. § 20.205. 2. The criteria for withdrawal of the appeal for entitlement to service connection for a hysterectomy have been met. 38 U.S.C. § 7105(d); 38 C.F.R. § 20.205. 3. The criteria for withdrawal of the appeal for entitlement to service connection for a dental condition have been met. 38 U.S.C. § 7105(d); 38 C.F.R. § 20.205. 4. The criteria for withdrawal of the appeal for entitlement to service connection for a chest condition have been met. 38 U.S.C. § 7105(d); 38 C.F.R. § 20.205. 5. Evidence received since the December 2002 rating decision is new and material, and reopening of the Veteran’s claim for entitlement to service connection for a left upper extremity condition is warranted. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156(a), 20.203, 20.1103. 6. The criteria for entitlement to service connection for a left upper extremity condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 7. The criteria for entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 8. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 9. The criteria for entitlement to service connection for a preexisting bilateral foot condition have not been met. 38 U.S.C. §§ 1110, 1153, 5107; 38 C.F.R. §§ 3.102, 3.306(a)–(b). 10. From October 7, 2014, to August 15, 2017, entitlement to a 70 percent disability rating, and no higher, for service-connected psychiatric condition have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9433. 11. From August 16, 2017, to November 5, 2019, entitlement to a disability rating in excess of 30 percent for service-connected psychiatric condition have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.130, DC 9433. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1996 to July 2002. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. A Board hearing was conducted at the RO in Louisville, Kentucky. A transcript of this hearing is contained within the electronic claims file. See November 6, 2019, Hearing Transcript (Tr.). In April 2020, VA sent to the Veteran a letter indicating that evidence since the Statements of the Case (SOCs) had been added to her claims file and requested that she either waive review of this evidence by the agency of original jurisdiction (AOJ) or have her case remanded back to the AOJ so that it could review the evidence in the first instance. Later that month, the Veteran indicated that she was waiving AOJ consideration of that evidence. Thus, the Board is permitted to review this evidence in the first instance, and remand in this instance is not required. See 38 C.F.R. § 20.1305(c). Voluntary Dismissal An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by a veteran or by an authorized representative and must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action by the appellant. Acree v. O’Rourke, 891 F.3d 1009, 1012 (Fed. Cir. 2018); DeLisio v. Shinseki, 25 Vet. App. 45, 57–58 (2011); 38 C.F.R. § 20.205. At the hearing, the undersigned Veterans Law Judge (VLJ) indicated that the appeals for whether new and material evidence has been received to reopen the claim for entitlement to service connection for numbness and pain in the right upper extremity and entitlement to service connection for a chest condition, a dental condition, and a hysterectomy were being withdrawn. The Veteran confirmed that this was correct and indicated that she understood that withdrawal of these issues would cause her to forfeit the effective date of her previous filing. Thus, the criteria for voluntary dismissal has been met, and the Board no longer has jurisdiction over these issues. Therefore, they are dismissed. See Acree, 891 F.3d at 1012; 38 C.F.R. § 20.205. New and Material Evidence VA may reopen a claim that previously has been denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers, and material evidence is evidence that, by itself, or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Regarding the newly submitted evidence, the United States Court of Appeals for Veterans Claims (Court) has held that 38 C.F.R. § 3.156(a) must be read as creating a low threshold, which suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 117–18 (2010). Furthermore, the Court has held that evidence as to each previously unproven element of a claim is not required for the claim to be reopened. Id. at 121. VA is required to review for newness and materiality only the evidence submitted by a claimant since the last final disallowance of the claim on any basis, whether a decision on the underlying merits or a petition to reopen. Evans v. Brown, 9 Vet. App. 273, 283 (1996). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, the credibility of the evidence generally is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of any RO determinations that new and material evidence has been submitted to reopen a previously denied claim, the Board still must review whether new and material evidence has been submitted. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). The Board notes that the November 22, 2017, SOC addressed the merits of the Veteran’s appeal for this issue. The VLJ, however, noticed that, because of the prior, final denial in December 2002, it would be required to assess whether new and material evidence was submitted to warrant reopening. At the time of the December 2002 final denial, the evidence of record consisted of service treatment records (STRs) and an October 2002 VA examination. VA ultimately denied the claim because there was no diagnosed condition of the left upper extremity and that only the Veteran’s subjective complaints of numbness and pain existed. Since that determination, the evidence of record consists of VA medical center (VAMC) records and testimony form the Veteran. Specifically, there is a May 2014 note in the VAMC treatment records that indicates hand discoloration and a possible diagnosis of Raynaud’s disease. Under the low threshold articulated by the Court in Shade, the Board finds that this evidence is new and material. The treatment records previously were not considered by VA adjudicators and relates to an unestablished fact necessary to substantiate the claim—the requirement for an actual diagnosis. Thus, this is new and material evidence, and reopening of the claim indeed is warranted. See 38 C.F.R. § 3.156(a). Service Connection To establish service connection, there must exist medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); 38 C.F.R. § 3.303(a). To establish secondary service connection, a veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond natural progression by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 446 (1995); 38 C.F.R. § 3.310. In rendering a decision on appeal, the Board must analyze the competency, credibility, and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Buchanan v. Nicholson, 451 F.3d 1331, 1335–37 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a left upper extremity condition is denied. For the purposes of service connection, pain alone, without any underlying pathology or disease process, can constitute a current disability if there is objective evidence that the pain causes functional impairment resulting in a decrease of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). STRs do not contain complaints of, treatment for, or diagnosis of a left upper extremity condition. The post-service medical records show, beginning in May 2014, that the Veteran mad complaints of pain in numbness in mostly her hand but sometimes in her arm. There also were complaints that her left fingertips and nail beds would turn purple, but there was no documented numbness or pain. A June 2014 entry that states that this occurs more frequently while at work, and the Veteran characterized the feeling as a “throbbing sensation,” but there was no numbness or weakness in her left arm and no shoulder pain. The VAMC records, however, do not confirm an actual diagnosis of Raynaud’s disease as previously noted as a possibility. At the hearing, the Veteran’s representative conceded that the medical evidence of record still lacked any formal diagnosis of a left arm condition and that they would be seeking a medical opinion to provide that evidence to the Board. See Tr. 6. To date, no such evidence has been received. Even considering the lower threshold provided in Saunders, however, the evidence of record does not establish that the Veteran’s subjective complaints of pain rises to the level of functional impairment that results in a decrease of earning capacity. While the Veteran did report that this pain sometimes occurs during work, there is no indication that it causes her to stop working, miss work, or otherwise experience a decrease in earning capacity. As such, because these complaints of pain do not rise to the level of a current disability, the first element of service connection has not been established and the Board need go no further with its analysis. See Saunders, 886 F.3d at 1363; Romanowsky, 26 Vet. App. at 293; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit); 38 C.F.R. § 3.303(a). 2. Entitlement to service connection for OSA is denied. The Veteran argues that she experienced symptoms of OSA while on active duty that have continued into the present. Alternatively, the Veteran asserts that her OSA is secondary to her service-connected hypertension. See October 12, 2016, Statement in Support of Claim. STRs reveal that, in September 1996, the Veteran had been unable to sleep secondary to complaints of low back pain for the last six months. The remaining STRs are silent for complaints of, treatment for, or diagnosis of OSA. In December 2015, the Veteran underwent a sleep study, which confirmed a diagnosis of mild OSA. In April 2016, the Veteran submitted a statement C.H., who indicated that he and the Veteran joined the military as a married couple. C.H. states that, while on active duty, the Veteran began experiencing sleep trouble, which caused her to fall asleep during daily meetings and at the wheel when driving. In a May 2017 statement, the Veteran indicated that there is a lot of pressure in her head, which, in turn, makes her very tired and sleepy, requiring that she lie down and take a nap. She alleges that she experienced these same symptoms while on active duty. In August 2017, the Veteran submitted various articles discussing the OSA and hypertension. In September 2017, VA obtained a medical opinion regarding whether the Veteran had OSA during active duty service. The examiner stated the following: It is LESS likely than not . . . that the [V]eteran’s [OSA] was incurred during active duty service. Loss of sleep due to pain and apparent resultant daytime drowsiness is not [OSA]. It has nothing to do with transient blockage of the airway while sleeping. The available lay and medical evidence does not support a diagnosis of [OSA] on active duty. No nexus. A subsequent, October 2017 VA opinion addressed the same question after considering an October 2016 statement from C.H. The examiner’s opinion remained unchanged and reiterated the previous findings and rationale. In November 2017, VA obtained an opinion to address the Veteran’s contentions that her OSA was caused or aggravated by hypertension, as well as the Veteran’s submitted articles. The examiner responded to each submitted article in turn and responded with the following: Comments regarding above articles regarding Veteran’s claim: 1. BC/BS [Web MD]: Only comments that hypertension “can” trigger OSA. Nothing in the article indicates that the Veteran’s case of OSA is more likely than not due to or aggravated by SC HTN. It also should be noted [that] the Veteran has not had hard-to-control HTN. Medical records review shows that on the occasions she has had elevated BP measurements, the staff has re-checked it and it has usually been in the normal range. This lessens the likelihood that her BP has caused or worsened OSA, based on the contents of the articles. 1. Ncbi.nlm.nih.gov: Shows greater statistical risk, but does not indicate that there is a greater than 50% li[k]elihood that a person with OSA got it or was worsened by HTN. Uses the term “may,” which is not strong support for the Veteran’s contention. The article’s conclusions about hypertension and OSA are based on the uses of information from individuals with metabolic syndrome (MetS). The Veteran does not have [MetS], so the article’s conclusions do not apply well to her situation, providing less support for her contention than would be needed in order to be persuasive. 2. Mayo Clinic: By use of the word “may,” the article does not provide persuasive support for the Veteran’s contention of a connection to service. The fact that a lot of people have both HTN and OSA does not [mean] that HTN caused OSA. Correlation (or association) is not causality (or aggravation). Review of UptoDate.com, an online peer-reviewed medical reference commonly used in clinical medical practice includes information on risk factors for OSA, and HTN is not one of those listed. This would indicate that while terms such as “may” or “can” are used in the above articles, it is not conclusive that HTN causes or aggravates OSA *** For the above reasons, the Veteran’s SC HTN as less likely than not secondarily caused or aggravated her OSA. The Board recognizes that Veteran currently has a diagnosis of OSA and that the Veteran experienced sleepiness during service. Thus, the first and second elements of direct service connection have been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). With respect to the third element of direct service connection, the Board finds that the evidence of record is insufficient. The September and October 2017 VA examiner (the same medical professional) opined that the Veteran’s OSA was not related to her in-service complaints of sleepiness, which was documented as due to lower back pain. The examiner noted that the daytime sleepiness attributed to poor sleep form pain has nothing to do with the structural composition of the Veteran’s airways and that the two completely are unrelated. While the Veteran is of the contrary opinion, arguing that this sleepiness was a manifestation of OSA, which continued into the present, the Board notes that the Veteran is not competent to offer such a complex medical opinion. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Thus, as the only competent and credible medical opinion of record, uncontradicted by the other competent and credible evidence of record, the Board affords the VA examiner’s opinions considerable probative value on appeal. Thus, the third element of direct service connection has not been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). With respect to secondary service connection, the Board recognizes the Veteran’s diagnosis of OSA, as well as the fact that she is service connected for hypertension. Thus, the first two elements of secondary service connection have been established. See Allen, 7 Vet. App. at 446; 38 C.F.R. § 3.310. Concerning the third element of secondary service connection, the Board finds the evidence of record insufficient. The November 2017 examiner responded to the articles submitted by the Veteran and adequately explained why each article does not provide enough support to conclude that the Veteran’s service-connected hypertension caused or aggravated the Veteran’s OSA. Furthermore, the examiner conducted independent research among peer-reviewed literature and concluded that there exists no evidence to support that hypertension causes or aggravates OSA. To paraphrase the examiner, correlation is not causation or aggravation. Thus, the Board finds that the third element of secondary service connection has not been met. Because the evidence of record does not support the Veteran’s claim for entitlement to service connection for OSA, to include as due to service-connected hypertension, the Veteran’s appeal is denied. The Board is unable to find an approximate balance of the positive and negative evidence submitted to warrant for the Veteran a favorable decision. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53; 38 C.F.R. §§ 3.102, 3.303(a), 3.310. 3. Entitlement to service connection for a low back disability is denied. The Veteran believes that her current back condition is related to her in-service complaints of lower back pain or, in the alternative, due to her service-connected right knee condition. See August 7, 2017, Correspondence; June 10, 2014, Statement in Support of Claim. STRs show that the Veteran complained of back pain on several occasions: July–September 1996. The assessment was muscle strain fatigue and muscle tightness in the lumbar region. The Veteran was prescribed Motrin. At the April 2002 separation examination, the Veteran’s spine was noted as normal. A post-service, October 2014 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examination highlighted two important medical notations in the Veteran’s VAMC records: most notably her December 2004 initial PCP visit, which was negative for back pain. In January 2012 the Veteran presented for back pain that started the month prior. The Veteran developed, while doing her daughter’s hair, sudden low back pain across both sides, which has gone down her buttocks and down her right leg. The examiner ultimately concluded that the Veteran’s back strain is not related to her in-service complaints of back, providing the following rationale: The Veteran strained her back, while doing her daughter’s hair, per 1/18/2012 CPRS note. The Veteran was diagnosed with a low back strain/pain on active duty that was “insidious” in it’s [sic] onset and [lasted] for several months. She appeared to have recovered from this condition while on active duty as she did not seek care for the problem for the remaining year of her service after her last visit for the problem. (She was seen many times between the last note regarding back pain and her ETS. This shows she was able to get to medical care when something bothered her; apparently the back was no longer a problem.) Also, the Veteran specifically denied recurrent back pain at her separation exam, and signed the form. The medical records indicate she also specifically denied back pain at her initial [visit] with her VA PCP 12/2004, about a year and a half after leaving the service. Since records gathered in the clinical setting are considered to be more probative, more weight has been given them, relative to lay evidence, in the formulation of this opinion. Onset of her back pain years later, apparently almost eleven years after ETS, [occurred] while doing her daughter’s hair. Due to this long gap in time between service and the back strain, there does not appear to [be] a medical nexus for the purposes of service connection. Additionally, the proximate cause for back pain appears to be related to doing her daughter’s hair. Of note, there is no mention of previous back pain in the 1/2012 note describing her back pain. At the hearing, the Veteran’s representative stated the following: For the low-back, there were times in-service that there were complaints in-service of issues with the low-back that persisted for several months at the beginning of [the Veteran’s] service. That then kind of corrected itself for the time being. So, we will be seeking an opinion to relate one; a current diagnosis of the low-back condition, as there is not one of record at this time; as well as an opinion linking that current diagnosis to the issues that were seen in-service. Tr. at 6–7. The Board notes that it is ambiguous whether the Veteran has a current back condition. The June 2014 examiner, however, seems to indicate that the Veteran currently suffers from a lumbar strain. On this issue, the Board will resolve all reasonable doubt in the Veteran’s favor and find that she has a current back condition for the purposes of service connection, satisfying the first element. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). The Board likewise acknowledges that the Veteran had several months of low back pain during service. Thus, the second element of service connection has been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). Turning to the third element of service connection, however, the Board finds that the evidence of record is insufficient. The June 2014 examiner noted that the Veteran’s in-service complaints of low back pain eventually stopped, that she had a normal spine at separation, and, once she established care with VA, there were no complaints of back pain until January 2012 when she injured her back while doing her daughter’s hair. While the Veteran believes that her bouts of in-service, low back pain are the cause of her current condition, she is not competent to provide such a complex medical opinion. See Jandreau, 492 F. 3d at 1377. While the examiner ultimately concluded that more probative weight is to be given medical records than to lay evidence, the Board disregards such statements from the examiner and recognizes that the Board is the ultimate adjudicator and entity responsible for assigning probative value to evidence of record. See Sizemore v. Principi, 18 Vet. App. 264, 275 (2004) (faulting a VA examiner for expressing an opinion on whether a Veteran’s claimed, in-service stressor was substantiated, which is a determination to be made by the Board); Pond v. West, 12 Vet. App. 341, 345 (1999) (holding that the issue of service connection is a “factual determination” to be made by the Board); Cf. Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (holding that medical examiners provide “a disability evaluation” while a “rating specialist interprets medical reports in order to match the rating with the disability). On the contrary, because the VA examiner’s opinion is the only competent and credible medical opinion of record, uncontradicted by the other competent and credible evidence of record, the Board affords it considerable probative value on appeal. Thus, it finds that the third element of service connection has not been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). The Board also acknowledges that the Veteran has argued that her service-connected right knee has caused her back problems. VA’s duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. 38 C.F.R. § 3.159(c)(4). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained, there are four factors that must be met: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 C.F.R. § 3.159(c)(4). The Veteran’s allegation, however, is not shown by the evidence of record. As the June 2014 examiner stated, the Veteran’s current back condition already has been attributed to her January 2012 back sprain while doing her daughter’s hair. The only evidence that the two conditions could be related is the Veteran’s own belief as such. A mere conclusory, generalized lay statement that a service event or illness caused the claimant’s current condition is insufficient to trigger VA’s duty to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278–79 (Fed. Cir. 2010) (“Since all veterans could make such a statement, this theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran’s disability case. If Congress had intended that requirement, presumably it would have explicitly so provided.”). Thus, there is not sufficient evidence to indicate that the Veteran’s service-connected right knee has caused or aggravated, beyond natural progression, her back condition. Thus, the Board has no obligation to secure a medical opinion with regards to secondary service connection. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 C.F.R. § 3.159(c)(4). 4. Entitlement to service connection for a bilateral foot disability is denied. The Veteran argues that her bilateral pes planus has existed since service, which, she believes, entitles her to compensation. See June 10, 2014, Statement in Support of Claim. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). An indication of past disorder or disability by a veteran on a report of medical history is not enough to prevent the presumption of soundness from attaching. Gray v. Nicholson, 21 Vet. App. 104 (2006). When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran’s disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any ‘increase in disability [was] due to the natural progress of the’ preexisting condition. 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the veteran’s claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004) (citing 38 C.F.R. § 3.322). Where a disability or disease is noted at the time of enlistment, a veteran is not presumed sound as to that disability. A veteran’s preexisting injury or disease, however, will be presumed to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). “The clear-and-unmistakable-evidence standard is an ‘onerous’ one... and requires that the no-aggravation result be ‘undebatable.’” Cotant v. Principi, 17 Vet. App. 116, 131 (2003). The veteran bears the initial burden of establishing that a worsening of a disability or disease occurred in service. If the veteran is successful, the presumption of aggravation attaches, and the burden shifts to the VA to demonstrate by clear and unmistakable evidence that any worsening is attributable to the natural progression of the disability. The Veteran’s August 1995 entrance examination noted that she had mild, asymptomatic pes planus. A May 2001 entry noted that the Veteran was experiencing pain in the feet, an inability to walk, and swelling of the shins. There were no other complaints of, treatment for, or diagnosis of any foot condition. The April 2002 separation examination also noted that the Veteran had mild, asymptomatic pes planus. In March 2013, the Veteran submitted a statement from her VA healthcare provider—Dr. K.D.—which stated that the Veteran currently is being treated for foot and knee pain, which is at least as likely as not related to her problems that developed during service. A May 2015 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examiner diagnosed the Veteran with bilateral pes planus and opined that the Veteran’s preexisting condition was not aggravated beyond its natural progression by military service. The provided rationale was as follows: 4-3-2002 Separation medical exam pes planus Mild Asymptomatic. She was seen in 5/2001 for bilateral lower leg and foot pain “[excruciating] to walk” ordered an us of her venous system. There is no [documentation] of her pes planus being the cause of her edema/leg/foot pain. [T]reated with elastic stockings indicating that it was NOT likely due to flat feet. [O]n 3/28/02 [Veteran] marked foot troubles mentioned corn on left foot small toe. Right foot big [toenail] peels off and arches. 4-17-02 Reason for visit Rt big toenail. C/O right toe (great) toenail intermittently coming off. Toe at this time has polish on it told to come back for culture. She did not follow up. [P]er Review of CPRS there are not records indicating worsening of a flat foot condition following service. She is not seen by podiatry until 2011 for a corn removal on left foot. There is no evidence [V]eteran’s pes planus was aggravated beyond the normal progression of the disease while in AD service. In his April 2016 statement, C.H. stated that, prior to joining the military, the Veteran “did not have any problems with her feet . . . .” He continued: It wasn’t until after being in the military a year or two that she started complaining about her feet . . . . She was only about [103 pounds] when she joined. She developed a corn on her left foot, calluses on her feet, and her legs and knees were swollen every day from wearing the military boots everyday and sometimes all day. *** As I said before, she didn’t have anything wrong with her when we joined the military. These issues only occurred and were caused after being in the military. In her August 2017 statement, the Veteran indicates that her bilateral foot pain was aggravated by having to carry a rucksack and duffel bag during basic training, as well as the constant marching and standing for long periods of time. Additionally, her duties as a chef required that she be on her feet for ten–fourteen hours a day. At the hearing, the Veteran’s representative stated that they would be seeking a medical opinion regarding in-service aggravation, see Tr. at 7; however, no such opinion has been submitted to the Board. As previously mentioned, the Veteran’s bilateral pes planus was noted at entrance to service as mild and asymptomatic. As such, the Veteran is not presumed sound as to her feet when she entered service, and the presumption of soundness does not attach. Thus, the Veteran can bring only a claim for aggravation of a preexisting condition. The presumption of aggravation automatically attaches if the Veteran’s preexisting condition undergoes an increase in disability during service. The Veteran bears the initial burden of establishing an increase in disability during service. See 38 U.S.C. §§ 1111, 1153; Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304(b), 3.306(a). The evidence of record does not establish that the Veteran experienced an increase in disability of her preexisting bilateral foot condition. The April 2002 separation examination noted that the Veteran’s pes planus remained mild and asymptomatic—the same status noted at entrance. The May 2015 VA examiner also opined that aggravation was not demonstrated and provided an adequate and supporting rationale. Dr. K.D. opined that the Veteran’s current foot condition are related to her foot condition while in service, but that legally is not the question that needs to be answered. Because the Veteran’s bilateral pes planus predated service, it naturally would have been present during service and, therefore, could not have developed during service as Dr. K.D. suggests. Because Dr. K.D. offers no medical opinion regarding in-service aggravation of the Veteran’s preexisting condition, her opinion is afforded little probative value on appeal. While C.H. is competent to report the extent of the Veteran’s foot pain, as he witnessed the Veteran, the Board does not find these statements credible. C.H. states that, prior to service, the Veteran “didn’t have any problems with her feet,” but that statement factually is refuted by the August 1995 entrance examination, which clearly documents that the Veteran had mild, asymptomatic pes planus. While the other conditions, such as a corn and calluses may have developed, the examiner noted that no in-service aggravation existed despite these occurrences. As such, the Board affords the VA examiner’s opinion considerable probative value on appeal and finds it most persuasive on the issue at hand. Because the Veteran has failed to meet her burden of establishing that her preexisting bilateral foot condition experienced any aggravation during her period of active duty service, her claim for service connection of a preexisting bilateral foot condition is denied. See 38 U.S.C. §§ 1111, 1153; Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004); 38 C.F.R. § 3.304(b), 3.306(a). Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. While a veteran’s entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. 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 veteran. 38 C.F.R. § 4.3. For psychiatric disabilities, a 100 percent disability rating contemplates 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. 38 C.F.R. § 4.130. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 10 percent rating requires occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant a particular rating, but are not meant to be exhaustive, and the Board need not find all, or even some, of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442–43 (2002). If the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a specific rating, the appropriate, equivalent rating will be assigned. Id. at 443. The rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116–17 (Fed. Cir. 2013). The Veteran originally was awarded service connection for her psychiatric condition in a July 2012 Decision Letter; she was granted a 30 percent disability rating effective February 29, 2012. The Veteran filed the instant increased rating claim in October 2014. When she filed her claim, the Veteran reported that she was having problems at work, sleeping, eating, nightmares, anxiety attacks, crying at work, an inability to focus, and being prone to anger and agitation. VAMC records show that, in pertinent part, the Veteran was receiving routine mental health treatment from April 2014 to March 2016 and then stopped seeking treatment. A March 2015 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examiner noted that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Noted symptoms were depressed mood, anxiety, and suspiciousness. At that time, the Veteran lived with her husband and her sixteen-year-old daughter and seventeen-year-old son; the family goes out to dinner about once a month. The Veteran talks on the phone to her mother every Sunday. The Veteran primarily socializes with a neighbor and her family but also has three close friends with whom she talks every few months. The Veteran sporadically attends church and enjoys playing online games and watching television in her spare time. With respect ot occupational functioning, the Veteran worked for the VA RO in Louisville, Kentucky, as a legal instrument examiner, working four, ten-hour days. The Veteran noted her job as stressful and experiencing conflict with management and some coworkers. The Veteran received verbal counseling that past July, and she explained that she sometimes calls in sick due to heightened emotional stress associated with her work conflict. Overall, the examiner provided the following comments: The Veteran was administered the Personality Assessment Inventory (PAI), a 344-item self-report scale that provides information about an individual’s clinical symptoms and personality features as well as validity measures for the individual’s response pattern. Certain validity indicators fall outside of the normal range, suggesting that the respondent may not have answered in a completely forthright manner. With respect to negative impression management, there are indications that the client attempted to portray herself in a consistently negative or pathological manner. Concerns about distortion of the [clinical] picture must be raised as a result; the respondent (perhaps without awareness) likely accentuates the negative aspects of herself and the environment [while] minimizing positive aspects. Although this pattern does not necessarily indicate a level of [distortion] that would render the test results uninterpretable, the clinical scale elevations may overrepresent the extent and degree of significant test findings in particular areas. The PAI clinical profile was marked by significant elevation across several clinical scales that include the following: ANX (t-score=91), ARD (t-score=83), DEP(t-score=102) MAN(t-score=70), PAR (t-score=101), SCZ (t-score=91), and BOR (t-score=76). Given certain response tendencies noted in the above paragraph, it is possible that the clinical scales may overrepresent or exaggerate the actual degree of psychopathology. Nonetheless, profile patterns of this type are usually associated with marked distress. The configuration of the clinical scales suggests a person with prominent depression and hostility. The [respondent] may be experiencing an embittered pessimism, with many of the negative circumstances occurring in her life attributed to the [shortcomings] of others, and she likely sees little hope that she can change these circumstances. Her heightened sensitivity in social interactions has led to significant withdrawal and probably serves as a formidable obstacle to the development of close relationships. She is likely to be plagued by thoughts of worthlessness, hopelessness, and personal failure and admits openly to sadness, a loss of interest in normal activities and a loss of a sense of pleasure in things that were previously enjoyed. She describes a level of suspiciousness and mistrust in her relations with others that is [unusual] even in clinical samples; such a pattern is often associated with prominent hostility and paranoia of potentially delusional proportions. She is likely to be a hypervigilant individual who often questions and mistrusts the motives of those around her; she is probably seen by others as being quite hostile and working relationships with others are likely to be very strained, despite any efforts by others to demonstrate support and assistance. She is likely to be a socially isolated individual with few interpersonal relationships that can be described as close and warm; her thought processes are likely marked by confusion, distractibility, and difficulty concentrating. She is likely to be plagued by worry to the degree that the ability to concentrate and attend are significantly compromised. Affectively, she likely feels a great deal of tension, has difficulty relaxing, and likely experiences fatigue as a result of high perceived tress. The respondent describes a number of problematic personality traits. She reports problems of many different types; she is likely to be quite emotionally labile, manifesting fairly rapid and extreme mood swings and in particular probably experiences episodes of poorly controlled anger. She appears uncertain about major life issues and has little sense of direction or purpose in her life as it currently stands. It is also likely that she has a history of involvement in intense and volatile relationships and tends to be preoccupied with fears of being abandoned or rejected by others. In April 2015, the Veteran submitted various statements from coworkers, supervisors, and union officials who commented on their observations of the Veteran in various settings. During a meeting, D.S. witnessed the Veteran become “visibly upset in the ways of crying and shaking uncontrollably to the point that she was unable to speak.” M.A. noticed that the Veteran exhibited a change in mood and behavior; while once social and happy, the Veteran, according to M.A., is not social, keeps to herself, and curses upon hearing the names of coworkers with whom she does not get along. T.W. notes that the Veteran was subjected to a hostile work environment and subsequently moved to another work area but that the Veteran fears retaliation from these coworkers. T.W. notes that, since the work incident, the Veteran has been physically and emotionally withdrawn. D.F. and N.C. both reported that the Veteran can become highly emotional while at work. A March 2017 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examiner noted that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Observed symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, gross impairment in thought processes or communication, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work and worklike setting, inability to establish and maintain effective relationships, obsessional rituals which interfere with routine activities, persistent delusions and hallucinations, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner also noted that the Veteran exhibited other symptoms, which were recorded: The Veteran appeared to demonstrate some symptoms which may be related to intense psychological distress related to experiences in her first marriage. The Veteran related that she often experiences intrusive thoughts, intense emotional reactions, and social interactions that trigger memories and experiences related to her experiences in her first marriage. The Veteran and her husband report that she often becomes suspicious of his behavior and/or the intentions of other women’s’ intentions towards him becoming quickly jealous and vocal. This has resulted in increased marital distress at times. Both the veteran and her husband acknowledge and explain an understanding that much of this comes from her experiences of infidelity, deviant sexual experiences, emotional turmoil, and potential physical violence. Furthermore, the veteran appears to be dealing with significant issues related to body image secondary to double mastectomy and reported hysterectomy and is questioning her value in the marriage. She reports that her self-care often is decreased, she is anhedonic, socially isolates, feels guilty and often as if she has not done or been meaningful on given days. Additionally, [t]he veteran reports that she continues obsessive hair pulling “every day” related to anxious distress. She reports that she has a history of biting nails and chewing on the inside of her mouth for the same reasons. As far as social functioning, the Veteran reported that she gets along well with her husband, but that she finds it difficult to be social with other individuals, particularly other women. As a result, they have little interaction with others outside the family and home. With respect to occupational functioning, the Veteran presented with no additional limitations since her last evaluation. Her work conflicts have subsided, and she made no additional work complaints. An August 2017 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran’s complaints and medical history. The examiner noted that the Veteran experienced occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Observed symptoms were depressed mood. The Veteran’s social functioning was not discussed in detail, but her relationships with her immediate family were described as “okay.” The Veteran was noted to have served in the role of a fiduciary service representative since June 2015. The pertinent observations were as follows: Overall, there appears to be a high level of thought dysfunction that likely impairs her interpersonal relationships. There is also symptoms of depression and anxiety, as well as manifesting somatic symptoms in response to psychological distress. Validity scale data while not invalid indicates she endorsed a higher than expected number of infrequent items and specifically endorse a pattern of responses strongly suggestive of non-credible memory complaints. A significant elevation in terms of thought dysfunction appears to be consistent with recurring themes of paranoia in her current marriage regarding fears her husband is interested in other women as well as other women being interested in him. She reports this fear started after an abusive marriage where her husband emotionally, physically and sexually abused her. In addition to what appears to be some level of thought dysfunction, there is emotional distress most notably in terms of depression. *** The Veteran did not report additional symptoms of depression or anxiety beyond those described in the PTSD exam below (“remarks” section of the report). She did not describe symptoms consistent with a history of panic attacks. She did not report symptoms consistent with a manic episode, mixed episode or hypomania. She reported average pain of 8/10 on scale of 1-10 in her feet, legs, knees and back that began 18 years ago. In an October 2017 Statement in Support of Claim, the Veteran expressed dissatisfaction with the August 2017 examiner and the way she was evaluated. At her hearing, the Veteran testified that she does not really have a social life that she works and then stays at home. The Veteran also testified to increasing problems sleeping and nightmares. See Tr. at 4. The Veteran’s representative indicated that the Veteran began resuming mental health treatment and requested that the Veteran be afford an updated examination, as her condition has worsened (discussed in more detail in the remand portion). See id. at 5–6. 5. From October 7, 2014, to August 15, 2017, entitlement to a 70 percent disability rating, and no higher, for service-connected psychiatric condition is granted. The effective date of an award for increased disability compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability has occurred, if the claim is received within one year from such date; otherwise, it is the date of receipt of the claim. 38 U.S.C. § 5110(b)(3); 38 C.F.R. § 3.400(o)(2). The Board notes that the Veteran filed this increased rating claim on October 7, 2014. The Board finds that, even assessing the evidence of record within one year prior to the Veteran’s increased rating claim, the date of the claim itself is the later of the date of filing and the date entitlement arose. During this time period, the evidence of record reflects that the Veteran’s psychiatric disability more closely approximates occupational and social impairment with deficiencies in most areas. The evidence shows that the Veteran frequently had trouble establishing and maintaining positive work relationships; she had various altercations that resulted in the need for union representation and relocating her workstation away from other coworkers. Several individuals have reported that the Veteran became overwhelmed while at work during meetings or upon hearing the names of coworkers with whom she did not have positive engagement. The March 2015 and 2017 VA examinations verify that the Veteran’s work was a source of great stress and anxiety for her and that she sometimes called in sick because she was so overwhelmed. With respect to social functioning, the March 2015 examiner noted that the Veteran’s heightened sensitivity in social interactions has led to significant withdrawal and probably serves as a formidable obstacle to the development of close relationships. She is likely to be plagued by thoughts of worthlessness, hopelessness, and personal failure and admits openly to sadness, a loss of interest in normal activities and a loss of a sense of pleasure in things that were previously enjoyed. She describes a level of suspiciousness and mistrust in her relations with others. The examiner continued: She is likely to be a socially isolated individual with few interpersonal relationships that can be described as close and warm; her thought processes are likely marked by confusion, distractibility, and difficulty concentrating. She is likely to be plagued by worry to the degree that the ability to concentrate and attend are significantly compromised. This information indicates to the Board that the Veteran experiences occupational and social impairment in most areas. Furthermore, the March 2017 VA examiner noted many symptoms indicative of a 70 percent disability rating. Thus, the Board will award the Veteran a 70 percent disability rating beginning October 7, 2014. See 38 C.F.R. §§ 3.400(o)(2), 4.130, DC 9433 For this time period, however, the Veteran is not entitled to a disability rating in excess of 70 percent. As the regulations make clear, a total disability rating for psychiatric conditions requires total occupational and social impairment. The Board notes that there is no evidence in the claims file that even indicates that the Veteran is unable to work at all and maintains no form of socialization with others solely due to her service-connected psychiatric condition. Indeed, as far as the Board is aware, the Veteran still is employed with VA, indicating that she is capable of working. The evidence, while displaying that the Veteran experiences considerable limitation on her social functioning has never shown that she experiences complete impairment in that area. Thus, the Veteran does not meet the criteria for a total disability rating for her psychiatric condition. See 38 C.F.R. § 4.130, DC 9433. 6. From August 16, 2017, to November 5, 2019, entitlement to a disability rating in excess of 30 percent for service-connected psychiatric condition is denied. Because this time period shows that the Veteran’s psychiatric condition improved, a staged rating is appropriate. See Hart, 21 Vet. App. at 509. The Board finds that, for this time period, the Veteran’s service-connected psychiatric condition more closely approximates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The August 16, 2017, VA examiner noted that the Veteran noted exhibited occupational and social impairment commensurate with a 10 percent disability rating. The only noted symptoms was depressed mood. By this time, the Board notes that there were no contemporaneous mental health treatment records for the examiner to evaluate in rendering her opinion as the Veteran stopped attending mental health appointments. This examiner commented on many facets of the Veteran, but there is no indication that the Veteran was experiencing the same level of occupational and social limitations that she previously was. To be sure, even by the time of the March 2017, the Veteran noted that her work conflicts had subsided, resulting in a decrease of stress for her occupational functioning. While social functioning still may have been impacted, any rating for a psychiatric condition requires concurrent occupational and social limitation. Thus, the Board finds that, for this time period, the Veteran’s assigned 30 percent disability rating is more appropriate. See 38 C.F.R. § 4.130, DC 9433. REASONS FOR REMAND 7. Beginning November 6, 2019, entitlement to a disability rating in excess of 30 percent for service-connected psychiatric disability is remanded. At the hearing, the Veteran testified that that her psychiatric condition “has gotten progressively worse; the representative noted that the Veteran was “beginning to seek treatment again in regards to this, because of the change, and how greatly it is affecting her and how little control she has been able to maintain.” The representative also noted that “it has been several years since her last mental health examination,” requesting that part of her claim be remanded to obtain an updated examination to reflect current findings. Neither the Veteran nor the representative confirmed whether the treatment the Veteran was going to seek would be private or through VA. In either scenario, VA has a duty to at least make reasonable attempts to obtain these records and to provide the Veteran with an updated examination. Thus, remand is required, and VA must take the prescribed action below. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (“We believe that fulfillment of the statutory duty to assist here includes the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one.”); 38 C.F.R. §§ 3.159(c)(1)–(2), 20.904(a). 8. Entitlement to SMC for loss of use of a creative organ, to include as secondary to service-connected hypertension or psychiatric condition, is remanded. The Veteran originally claimed service connection for loss of libido and loss of use of a creative organ as due to a full hysterectomy, which stemmed from abdominal pain while in service. The Veteran also alleged that her loss of libido was due to her service-connected hypertension. See June 10, 2014, Statement in Support of Claim. With the withdrawal of the hysterectomy claim, the VLJ reframed the issue on appeal to entitlement to SMC as it appears on the second page of this decision. A veteran is entitled to SMC if, as the result of service-connected disability, he or she has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114(k). Loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. 38 C.F.R. § 3.350(a)(1)(i). The regulations, however, advised that VA should consider whether SMC is warranted pursuant to 38 C.F.R. § 3.350 for, among other conditions, female sexual arousal disorder (FSAD). See 38 C.F.R. § 4.116, DC 7632. An October 2014 VA examination notes that the Veteran was diagnosed with hypoactive sexual desire disorder. The Veteran’s hysterectomy was performed in November 2009. This examiner noted that the Veteran did not have a diagnosis of FSAD; rather, she has decreased libido. A later June 2017 examiner opined that the Veteran’s decreased libido was not due to her service-connected hypertension but was attributed to her psychiatric condition. Because FSAD is considered to be a psychiatric diagnosis, and because neither the October 2014 nor the June 2017 examiners were a mental health professional, the Board conclusively cannot say that the Veteran does not have FSAD in accordance with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Thus, when the Veteran is evaluated for her psychiatric condition, as specified above, it will request an opinion regarding this issue. See 38 C.F.R. § 20.904(a). The matter is REMANDED for the following action: 1. Obtain any ongoing VA treatment records for the Veteran’s psychiatric condition. Should they exist, associate them with the claims file. 2. Send the Veteran the necessary forms to identify any private treatment she has received for her psychiatric condition and afford her the opportunity to complete and submit those forms. VA also must send the Veteran forms necessary to authorize VA to obtain these records on the Veteran’s behalf. If the Veteran identifies any records, then make reasonable attempts to obtain those records. Such attempts must be documented in the claims file. 3. After the above-record development has been completed afford the Veteran the opportunity to attend a psychiatric examination to assess the current severity of her condition. The examiner also must answer the following: (a.) Does the Veteran have a diagnosis of FSAD? (b.) If so, what is the date the Veteran first exhibited FSAD? (c.) If so, is it at least as likely as not (a fifty percent probability or greater) that the Veteran’s service-connected psychiatric condition proximately caused or aggravated, beyond natural progression, her FSAD? Note: The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. A detailed rationale supporting the examiner’s opinions must be provided. The lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 4. Conduct any other development deemed necessary and then readjudicate the Veteran’s claim. If the claim cannot be granted in full, then issue to the Veteran a supplemental statement of the case. After allowing an appropriate amount of time for response from the Veteran, return the claim to the Board. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or United States Court of Appeals for Veterans Claims must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Trevor T. Bernard, 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.