Citation Nr: 20044053 Decision Date: 06/30/20 Archive Date: 06/30/20 DOCKET NO. 17-27 764 DATE: June 30, 2020 ORDER Entitlement to an increased 10 percent rating, but no higher, for right foot residuals or removal of ingrown great toenail, is granted. Entitlement to an increased 10 percent rating, but no higher, for left foot residuals or removal of ingrown great toenail, is granted. Entitlement to restoration of a 50 percent rating for migraine headache variants, effective from the July 20, 2016, date of the voided reduction, is granted. Entitlement to a 10 percent rating for allergic rhinitis with chronic sinusitis is granted. REMANDED The issue of entitlement to a rating in excess of 10 percent for left ankle collateral ligament sprain is remanded. The issue of entitlement to a rating in excess of 10 percent for allergic rhinitis with chronic sinusitis is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran’s residuals of removal of right ingrown great toenail have been manifested by pain, instability, deformity, interference with standing and weight-bearing, and functional deficit representing a combination of impairments reasonably analogous to a painful and unstable scar plus further impairment reasonably analogous to metatarsalgia; the combination of impairments most reasonably approximates a moderate degree of impairment of the right foot, but no greater degree of impairment. 2. Throughout the rating period on appeal, the Veteran’s residuals of removal of left ingrown great toenail have been manifested by pain, instability, deformity, interference with standing and weight-bearing, and functional deficit representing a combination of impairments reasonably analogous to a painful and unstable scar plus further impairment reasonably analogous to metatarsalgia; the combination of impairments most reasonably approximates a moderate degree of impairment of the left foot, but no greater degree of impairment. 3. A February 2015 RO rating decision granted an increase in the Veteran’s rating for migraine headaches, from 30 percent to 50 percent, based upon a January 2015 VA rating examination; an August 2016 RO rating decision decreased the Veteran’s rating for migraine headaches, from 50 percent back to 30 percent, based upon a July 2016 VA headaches rating examination showing substantially the same degree of headache disability without significant improvement (despite ameliorating effects of new medication). 4. Throughout the rating period on appeal, there is no controversy as to the fact that the Veteran’s allergic rhinitis with chronic sinusitis has manifested in at least 3 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. CONCLUSIONS OF LAW 1. The criteria for an increased schedular rating of 10 percent (but no higher) for impairment of the right foot due to residuals of removal of right great toenail have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, 4.118, Diagnostic Codes 5279, 5284, and 7804. 2. The criteria for an increased schedular rating of 10 percent (but no higher) for impairment of the left foot due to residuals of removal of left great toenail have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, 4.118, Diagnostic Codes 5279, 5284, and 7804. 3. The decision of the Regional Office (RO) to reduce the rating for migraine headaches from 50 percent to 30 percent was not proper, and thus void ab initio; the criteria for restoration of a 50 percent rating for migraine headaches are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.124a, Diagnostic Code 8100; Greyzck v. West, 12 Vet. App. 288, 292 (1999). 4. The criteria for a 10 percent rating for allergic rhinitis with chronic sinusitis have been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 4.97, Diagnostic Code 6513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from November 1993 to November 1995. This matter is before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA), or the Agency of Original Jurisdiction (AOJ). The issues of entitlement to restoration of a 50 percent rating for migraine headache variants, entitlement to an increased rating for left ankle disability, entitlement to an increased rating for allergic rhinitis with chronic sinusitis, and entitlement to increased ratings for residuals of removal or right and left ingrown great toenails are before the Board on appeal from an August 2016 RO rating decision. The issue of entitlement to a TDIU is before the Board on appeal from a September 2016 RO rating decision. The Board notes that the Veteran additionally perfected an appeal on an issue concerning an overpayment of VA compensation benefits, and that issue was addressed and resolved by a separate Board decision issued in May 2020. The Board also notes that the May 2017 statement of the case (issued in the preparation of this appeal) included the additional issue of entitlement to an increased rating for bronchial asthma. There has since been some confusion with regard to whether the bronchial asthma issue is in appellate status before the Board at this time (including with reference to the inclusion of the issue in the April 2020 Informal Hearing Presentation submitted by the Veteran’s representative). However, the issue is -not- in appellate status before the Board, as the Veteran did not timely perfect an appeal of this particular issue for Board review. One of the timely filed June 2017 VA Form 9 submissions specifically limited its appeal to the rhinitis / sinusitis, ingrown great toenails, and left ankle issues. Another of the timely filed June 2017 VA Form 9 submissions specifically limited its appeal to the overpayment debt issued addressed by the Board in a separate decision in May 2020. The last of the timely filed June 2017 VA Form 9 submissions specifically limited its appeal to migraine headache rating reduction / restoration issue. As the Veteran has not perfected an appeal on the bronchial asthma issue to the Board for review, the Board does not have jurisdiction over the matter and shall not further discuss it in this decision. The Board also notes that the Veteran’s October 2016 notice of disagreement, central to the appeal of several of the issues currently before the Board, appears to attempt to initiate appeals of additional issues. The Board has carefully reviewed this matter to ensure that the Veteran receives due consideration of all appeals she may have initiated. Of the issues referenced by the Veteran in the October 2016 notice of disagreement that have not been addressed by a statement of the case, the Board finds that none were a timely appeal (within the one year appeal window) of any matter addressed in a recent RO rating decision. To the extent that the October 2016 notice of disagreement suggests a desire to appeal for an increased rating for migraine headaches (as distinguished from the separate issue of challenging the validity of the rating reduction, which is addressed in this Board decision), the Board notes that the most recent RO rating decision addressing the referenced claim for an increased rating for headaches was issued in February 2015; the October 2016 notice of disagreement was not timely to initiate an appeal of that decision (as it was not filed within a year of the issuance of that decision). To the extent that the October 2016 notice of disagreement suggests a desire to appeal a rating decision regarding the right ankle in addition to the left ankle (with a left ankle rating issue being addressed by the Board in this decision), the Board finds that the October 2016 notice of disagreement was not timely to any rating decision concerning any issue involving a right ankle disability. To the extent that the October 2016 notice of disagreement suggests a desire to appeal a rating decision regarding “OP,” the Board has determined that this is intended as a reference to “overpayment” (as indicated by an attached statement), and thus the issue has been addressed by a statement of the case and ultimately the Board’s May 2020 decision, discussed above. Increased Rating Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter 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 layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issues on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. Additional references to the Veteran’s pertinent health and disabilities on appeal are presented in evidence of record beyond that discussed below, including in VA medical reports associated with the Veteran’s treatment. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. 1. Entitlement to an increased 10 percent rating, but no higher, for right foot residuals of removal of ingrown great toenail, is granted. 2. Entitlement to an increased 10 percent rating, but no higher, for left foot residuals of removal of ingrown great toenail, is granted. The Veteran has appealed for increased ratings for her service-connected residuals associated with the removal of the ingrown great toenails of both the right and the left feet. The rating period on appeal for this matter begins with an April 27, 2016, claim for increase pertaining to the service-connected residuals of the right and left foot / great toe disabilities. The Veteran’s residual disabilities of removal of bilateral ingrown great toenails are currently rated 0 percent / noncompensably disabling. The foot conditions are not listed in the rating schedule, and therefore they are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284, for foot injuries “other” than those expressly covered by alternative Diagnostic Codes. Under Diagnostic Code 5284, a 10 percent rating is warranted where the foot injury is of a “moderate” degree; a 20 percent rating is warranted where the foot injury is of a “moderately severe” degree; and a 30 percent rating, which is the highest rating available under this schedule, is warranted where the foot injury is of a “severe” degree. Id. The Board notes that terms such as “moderate” and “severe” under applicable Diagnostic Codes are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The Veteran seeks compensable ratings for the disabilities of either foot. A July 2016 VA foot examination report prepared for rating purposes focuses upon identifying the disabling residuals of the reconfirmed diagnosis of “[r]emoval of ingrown toenails bilateral.” The report shows that the Veteran reported problems with recurrence of the great toenails “tear[ing] off,” not properly or completely re-growing, and that the “current problems with great toenails are ‘easy infections, discoloration, not growing back 100%, pain in my right one.” The Veteran more specifically described pain in both great toenails. The right great toenail featured “Aching, throbbing, probably a 7 out of 10.” The left great toenail “hurts if I bump it or try to clean it out, or when it’s really really cold.” The Veteran reported that during “flare-ups” she experienced further “[a]ching, throbbing,” and she described: “If I put pressure on it, it feels like my nail is pushing into my skin.” The Veteran reported functional loss / impairment: “I can’t really be on my feet or walking and running or being on my feet for long periods of time. I can’t kick a ball. I can’t wear anything that sho[w]s my toes because of what they look like. It affects my self esteem and my self-image because it makes me uncomfortable when they are seen.” The July 2016 VA examination report notes that the Veteran’s toenails were “[t]reated topically with a cre[am] for nail bed inflammation.” At the time of the July 2016 clinical inspection of her toes, the VA examiner noted that there was not currently pain on the right great toenail because the Veteran “[d]oes not currently have acute inflammation of ingrown toenail.” However, the VA examiner clinically observed pain in the left great toenail that “contribute[s] to a functional loss.” The VA examiner noted impairment on “Both” sides from “Pain on weight-bearing,” “Deformity,” and “Interference with standing.” The VA examiner noted that, for -both- great toes, “pain, weakness, fatigability, or incoordination … significantly limit[] functional ability during flare-ups or when the foot is used repeatedly over a period of time.” For both great toes, the VA examiner described: “Pain, weakness, fatigability limit how long she can bear weight during flare-ups or with repeated use over time.” The VA examiner observed “[e]nlarged nail borders medial & lateral great toenails bilaterally residual to prior ingrown toenail infections.” Additionally, “R[igh]t hallux lateral nail border peeling from most recent infection,” and “Left hallux nail is hypertrophic with yellowish crumbly borders, mildly tender at nail borders, without erythema or evidence of purulence.” Notably, the July 2016 VA examiner found “[m]ild tenderness of nail borders bilat[eral] hallux.” The VA examiner noted that there was “no objective evidence of a prolonged gait abnormality due to the ingrown toenail condition.” Rather, the VA examiner found that the Veteran “[h]as difficulty doing prolonged standing or prolonged walking, run[n]ing, jumping, climbing, kneeling, operating heavy foot pedals or do[ing] heavy lifting during flare-ups of great toenail infections.” The Board notes that an April 2017 VA foot examination report is focused upon a different foot diagnosis and does not present significant information enhancing the Board’s understanding of the great toenail disabilities. The Board finds that the evidence of record contains no evidence that otherwise significantly contradicts, expands, or updates the detailed depiction of the Veteran’s bilateral great toenail disabilities in this case; there is no evidence of record indicating a significant change in the nature or severity of the great toenail disabilities relative to the detailed July 2016 VA examination report on the matter. Based on the evidence of record, the Board finds that higher / compensable ratings are warranted. For the purpose of determining how to rate the severity of the Veteran’s impairment of each foot due to the toenail disabilities, the Board has taken careful consideration of the fact that the symptoms feature pain, tenderness to contact, and unsightliness associated with skin-level disease. With this in mind, the Board has looked to the schedular criteria for rating scars for some guidance as to the degree of compensability for impairment of this nature. 38 C.F.R. § 4.118, Diagnostic Code 7804, pertains to unstable or painful scars, and provides compensable ratings for scars that are unstable or painful. The Board finds that this suggests that the Veteran’s painful great toenail symptoms can be fairly understood to be compensably disabling under the principles of the rating schedule. The Board further recognizes that separate ratings for each foot are available under Diagnostic Code 5284 and, as such, the Board has considered whether separate ratings under Diagnostic Code 5284 are warranted for the Veteran’s right and left great toenail disabilities. The Board notes that the evidence clearly shows that the great toenail disabilities feature impairment compatible with that contemplated by the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7804, for unstable or painful scars, including the elements of unsightly appearance, pain, and tenderness to touch. Considering only these scar-like aspects of the Veteran’s impairment, the impairment might be arguably analogous to two painful and/or unstable scars. 38 C.F.R. § 4.118, Diagnostic Code 7804, provides that “One or two scars that are unstable or painful” warrant a single 10 percent rating, while 38 C.F.R. § 4.118(b) provides: “Two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used.” The Board finds that the great toenail disabilities of either foot are in “separate areas of skin,” but they arguably might not involve different “conditions” that would warrant a separate 10 percent rating for each great toenail under the principles of the rating schedule pertaining to scars. However, further exploring the guidance to be derived from the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7804, the Board notes that the Veteran’s great toenail disabilities may arguably be analogous to painful -and- unstable scars inasmuch as the recurrent infections result in recurring loss of the toenail coverings. “Note (2)” for Diagnostic Code 7804 provides that “If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.” To the extent that the Board seeks to take guidance from 38 C.F.R. § 4.118, Diagnostic Code 7804, to inform rating the Veteran’s great toenail disabilities, the Board notes that a 20 percent combined rating may be suggested for two scars that are both painful -and- unstable; a 20 percent combined rating would essentially match the level of compensation for a possible award of two separate 10 percent ratings for the great toenail disabilities under Diagnostic Code 5284. Alternatively, the Board notes that the Veteran’s bilateral great toenail impairment may arguably be likened to metatarsalgia foot pain. 38 C.F.R. § 4.71a, Diagnostic Code 5279, provides that anterior metatarsalgia warrants a single 10 percent rating, regardless of whether it is unilateral or bilateral. The Board has considered this guidance in its efforts to arrive at a rating determination in this case. However, the Board finds that the scar-like impairments of the great toe disabilities involve a broader set of impairments beyond the scope of those contemplated by the rating provisions for metatarsalgia. The Board finds that the Veteran’s bilateral great toenail disabilities feature pain interfering in weight bearing and foot function in a manner somewhat analogous to metatarsalgia, but the bilateral great toenail impairments feature, in addition to the pain and tenderness, additional features that are not contemplated by the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5279, concerning metatarsalgia. The recurring infections, skin inflammation, loss of nail covering, and resulting unsightly appearance of the toes are more compatible with a pair of painful and unstable scars that can be assigned compensation at a 20 percent rating level under 38 C.F.R. § 4.118, Diagnostic Code 7804. While the Board has looked to the provisions of other Diagnostic Codes for guidance, the Board’s analysis now returns to the fact that the bilateral great toenail disabilities are currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284, as foot disabilities “other” than those specified in other Diagnostic Codes. In light of the above, the Board finds that the impairment resulting from the disability in each great toenail is “moderate” in degree, warranting a 10 percent rating. Separate ratings for each foot are available under Diagnostic Code 5284, and the Board finds that a separate 10 percent rating for the impairment of the right great toenail, and a separate 10 percent rating for the impairment of the left great toenail, is warranted in this case. The Board notes that this is essentially compatible with the 20 percent rating level that would be awarded if the impairments were rated as analogous to a pair of scars that are painful and unstable under 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board finds that the evidence does not provide a basis for any further increased ratings for the Veteran’s great toenail disabilities this case. As discussed above, the Board has carefully considered guidance from provisions of the rating schedule to find a basis for determining that the impairment of each great toenail can be characterized as “moderate” for rating purposes in applying Diagnostic Code 5284. The Board has resolved reasonable doubt in the Veteran’s favor in seeking the maximum grant of benefits supportable by the evidence in this case; the Board finds that the collection of evidence and information considered in this analysis does not depict impairment of either foot from the great toenail disabilities that is greater than “moderate” in degree. Again, as discussed above, the Board has considered the guidance of the schedular rating provisions pertaining to scars and the feet to conclude that no further increased ratings are warranted in this case. In denying any further increased ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. While the Board has resolved reasonable doubt in the Veteran’s favor to award entitlement to increased / compensable ratings for the right and left feet / great toes dating back to the April 27, 2016, date of the claim, the Board finds that no compensable rating is warranted for any portion of the pertinent one-year period prior to the filing of the claim. The Court and VA’s General Counsel have interpreted the laws and regulations pertaining to the effective date for an increase as providing that, if the increase occurred within one year prior to the claim, the increase is effective as of the date the increase was factually ascertainable. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o)(1)(2); VAOPGCPREC 12-98 (1998). In this case, the Board has awarded an increased 10 percent rating for the right foot / great toe and an increased 10 percent rating for the left foot / great toe, effective from the April 27, 2016, date of the claim. The Board has now considered whether any worsening of disabilities within one year prior to the claim warranted an increased rating. However, the Board finds no evidence making it factually ascertainable that the Veteran’s right or left foot / great toe disabilities underwent an increase in severity to meet the criteria for a compensable rating on any identifiable date within a year prior to the April 27, 2016, date of claim. The Board has considered whether there is any other basis for granting further increased and/or additional ratings, but has found none. The Board finds that no further increased and/or additional ratings are warranted in this case. As the preponderance of the evidence is against assignment of any further increased and/or additional ratings in this case, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Neither the Veteran nor her representative has raised any other issues, beyond what is addressed in this decision, nor have any other issues been reasonably raised by the record in connection with the left upper extremity disability. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to restoration of a 50 percent rating for migraine headache variants, effective from the July 20, 2016, date of the voided reduction, is granted. A February 2015 RO rating decision granted an increase in the Veteran’s rating for migraine headaches, from 30 percent to 50 percent, effective from January 21, 2015. This grant of the increased rating was based upon the findings presented in the report of a VA headaches rating examination performed on January 21, 2015. An August 2016 RO rating decision decreased the Veteran’s rating for migraine headaches, from 50 percent back to 30 percent, effective from July 20, 2016. This decrease in the rating was based upon the findings presented in the report of a VA headaches rating examination performed on July 20, 2016. The Veteran’s appeal features the contention that the rating reduction was improper, and she seeks restoration of the 50 percent rating. The Board finds that restoration of the 50 percent rating is warranted. Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When the rating criteria are successive, as in the case of Diagnostic Code 8100 for migraine headaches, all the requirements of the lower ratings must be met before a higher rating is awarded. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The Veteran’s service-connected headaches are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100, as migraine headaches. Under Diagnostic Code 8100, a 10 percent disability rating is warranted for characteristic prostrating attacks, averaging one in 2 months over the last several months. A 30 percent disability rating is assigned for headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is assigned for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. When considering a disability rating, the Board must not consider the ameliorative effects of medication unless those effects are explicitly contemplated by the relevant rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 61 (2012). In this case, the Veteran’s headache pathology is rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, which does not mention the effects of medication. Thus, the ameliorative effects of the Veteran’s medications are not for consideration in rating her headache pathology. VA regulations, including the rating criteria, do not define prostrating as used in Diagnostic Code 8100. The Board notes that according to WEBSTER’S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, Third College Edition (1986), p. 1080, prostration is defined as utter physical exhaustion or helplessness. A similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th ed. 1994) in which prostration is defined as extreme exhaustion or powerlessness. The Court of Appeals for Veterans Claims has found that the phrase characteristic prostrating attacks means attacks that typically produce powerlessness or a lack of vitality. Johnson v. Wilkie, 30 Vet. App. 245 (2018). In other words, the term prostrating takes on its plain meaning of lacking in vitality or will; powerless to rise; laid low. Id. Pursuant to 38 C.F.R. § 3.105(e), where a reduction in the rating of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Final rating action will reduce or discontinue the compensation effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. The due process protections of 38 C.F.R. § 3.105(e) do not apply in this case because the August 2016 rating decision reducing the rating at issue, in the context of the other rating determinations and the Veteran’s combined disability ratings, did not result overall in a reduction or discontinuance of compensation payments. Prior to the August 2016 rating decision, the Veteran’s combined rating for all service-connected disabilities was 70 percent, as documented in the Codesheet for the prior February 2015 RO rating decision. Following the August 2016 rating decision, the Veteran’s combined rating for all service-connected disabilities was still 70 percent. The August 2016 RO rating decision did additionally include a grant of an increased rating for a different disability with retroactive effect such that the Veteran’s combined rating was increased to 80 percent for a period from April 27, 2016, to July 20, 2016. The combined rating returned to 70 percent from the effective date of the reduction of the migraine headaches rating. In aggregate, the August 2016 RO rating decision did not result in an overall reduction or discontinuance of compensation payments relative to the compensation entitlements in effect prior to the issuance of that rating decision. Rating agencies will handle cases affected by change of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation. It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations that are less thorough than those on which payments were originally based will not be used as a basis for reduction. Ratings for diseases subject to temporary or episodic improvement will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). The above considerations apply to ratings which have continued for long periods at the same level (five years or more), and do not apply to disabilities which have not become stabilized and are likely to improve. The Veteran’s 50 percent rating for migraine headaches was in effect for less than 5 years, from January 2015 to July 2016. When the provisions of 38 C.F.R. § 3.344(a) and (b) do not apply, for unstabilized ratings for disabilities likely to improve, reexaminations disclosing improvement in these disabilities will warrant reduction in rating. 38 C.F.R. § 3.344(c). The Board notes that it has reviewed all of the evidence of record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The law provides that where a rating reduction was made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, the erroneous reduction must be vacated and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of considering whether actual improvement was demonstrated. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The Veteran need not demonstrate that he or she is entitled to retain the higher rating; rather, in order for a rating reduction to be sustained, it must be shown by a preponderance of the evidence that the reduction was warranted. Sorakubo v. Principi, 16 Vet. App. 120 (2002). See also Brown, supra; Kitchens, supra. The Board finds that the rating reduction in this case was not warranted because the pertinent VA rating examination reports do not show sufficient improvement to justify the reduction. The January 2015 VA examination report serving as the basis of the award of the 50 percent rating shows, in pertinent part, that the Veteran reported “Severe prostrating headaches 1x/wk x 4-5 hours.” These were described in detail, including with reference to nausea, sensitivity to light, sensitivity to sound, and dizziness with “severe headaches.” At that time, she used over the counter medication but was “[n]ot currently on Rx for headaches.” The Board understands this as documenting the Veteran’s report of weekly prostrating headaches treated with only over-the-counter medications. The January 2015 VA examiner then checked a box to indicate “characteristic prostrating attacks” with a frequency of “Once every month.” It appears that the RO’s award of a 50 percent rating on the basis of this VA examination report was the result of the RO accepting the Veteran’s documented description of her own headache experience, and not treating the marked checkbox from the VA examiner as determinative for rating purposes. The July 2016 VA examination report was prepared by the same VA examiner that authored the June 2015 VA examination report. The July 2016 VA examination report, serving as the basis for the reduction of the 50 percent headache rating, is notably similar to the January 2015 VA examination report that served as the basis for the award of the 50 percent rating. The report shows that the “Veteran reports incapacitating (prostrating) headaches 1-2 x/week, more severe than usual during menstrual cycles.” She described experiencing nausea, vomiting, sensitivity to light, and changes in vision. The July 2016 VA examination report shows that in the time since the January 2015 VA examination, the Veteran had started using the prescription medication “Propranolol” and that this “helped somewhat to diminish the severity of her headaches.” Once again, just as was the case with the January 2015 VA examination report, the VA examiner checked a box to indicate “characteristic prostrating attacks” with a frequency of “Once every month.” Just as was the case with the January 2015 VA examination report, this indication was in contrast to the Veteran’s report of significantly more frequent prostrating attacks. It appears that the RO’s reduction of the 50 percent rating to 30 percent, on the basis of this July 2016 VA examination report, was the result of the RO no longer accepting the Veteran’s documented description of her own headache experience, and instead now treating the marked checkbox from the VA examiner as determinative for rating purposes. The Board finds that a comparison of the pertinent findings in the January 2015 VA examination report and the July 2016 VA examination report do not reveal improvement of the Veteran’s headache impairments to justify a rating reduction. Rather, the Board finds that the two VA examination reports generally depict the same level of impairment, with perhaps the most notable difference being that the Veteran had begun receiving additional treatment with a prescription medication that “helped to somewhat diminish the severity of her headaches.” The Board notes that the Veteran has asserted, in her September 2016 notice of disagreement, that she would be experiencing more severe symptomatology “if I was not on my medications.” Of course, the ameliorating effects of medication shall not serve as the basis for a proper rating reduction in this case featuring the rating criteria for headaches. Moreover, the Board is unable to find that the headache impairment experience described in the July 2016 VA examination report shows any meaningful improvement relative to the headache impairment experience depicted in the January 2015 VA examination report upon which the 50 percent rating award was based. It appears to the Board that rating reduction was the result of a change in how the RO viewed the findings presented in the two VA examination reports, not any change in the headache impairment depicted in those reports. The RO assigned a 50 percent rating based upon accepting the Veteran’s own account of the frequency and severity of her headaches rather than the checkbox selected by the VA examiner in the January 2015 report. It appears that the RO reduced the rating based upon rejecting the Veteran’s substantially similar account of the frequency and severity of headaches in the July 2016 report, and instead accepting the same VA examiner’s repetition of the selection of the same checkbox in July 2016 that she had selected in January 2015. The RO’s change in view regarding the Veteran’s consistent report of her headache symptomatology, without an indication of an actual improvement in the headache disability, is not a valid basis for a rating reduction. The Board does not otherwise find an adequate basis for the rating reduction at issue in this case. Accordingly, restoration of the 50 percent rating for migraine headaches is warranted in this case. The appeal is granted. 4. Entitlement to a 10 percent rating for allergic rhinitis with chronic sinusitis is granted. As discussed below, the Board finds that the Veteran is entitled to a new and updated VA examination to clarify the extent of new health developments pertinent to her claim of entitlement to an increased rating for allergic rhinitis with chronic sinusitis. However, the Board’s preliminary review has revealed a plainly clear error in the RO’s denial of a compensable rating based upon the July 2016 VA examination report of record; the error is apparent on the face of the May 2017 statement of the case addressing this matter. The Board shall here briefly remedy this plainly apparent error before returning the issue for the needed additional development. Prompt correction of this error may benefit the Veteran in the pending AOJ adjudication of the TDIU issue on appeal in that it will now be clear that the Veteran’s pertinent service-connected disability set includes rhinitis / sinusitis that is established to be disabling at a compensable level. This disability is rated under the provisions of 38 C.F.R. § 4.97, Diagnostic Code 6513, for chronic maxillary sinusitis. Under the General Rating Formula for Sinusitis (Diagnostic Codes 6510 through 6514), a 10 percent rating is warranted if the disability manifests in three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The July 2016 VA “Sinusitis, Rhinitis” rating examination report clearly and unequivocally documents the VA examiner’s finding that the Veteran experienced “3” such episodes, specifically “non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months.” The RO’s May 2017 statement of the case acknowledges this fact: “You are shown to have 3 non-incapacitating episodes of sinusitis over the past 12 months….” No contrary indication of record is noted by the RO’s adjudications of this matter, nor otherwise apparent to the Board’s review. The RO’s August 2016 rating decision and the May 2017 statement of the case both then erroneously assign a non-compensable rating based upon “no compensable symptoms.” It is apparent to the Board that this represents an error in the preparation of the statement of the case. As the Board’s jurisdiction for appellate review affords the opportunity here for a simple and immediate correction of this plain error, it shall here do so without delay. Based upon the established facts clearly and correctly stated in the May 2017 statement of the case, the Veteran is clearly entitled to at least a 10 percent rating for allergic rhinitis with chronic sinusitis from the April 27, 2016, date of claim. The Veteran’s appeal for higher ratings for this disability remains pending and is addressed in the remand section, below. REASONS FOR REMAND 1. The issue of entitlement to a rating in excess of 10 percent for left ankle collateral ligament sprain is remanded. The April 2017 VA ankle disability rating examination report documents that the Veteran reported “Yes,” that she does experience “flare-ups” of her left ankle disability. The VA examiner noted that “No,” the examination was -not- “conducted during a flare-up.” Nevertheless, the VA examiner did find that “Yes,” it is the case that “pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up,” and the VA examiner further specified that the factors causing such functional loss were “Pain, Fatigue, Weakness, Lack of endurance, Incoordination.” However, the VA examiner declined to estimate the flare-up impairment “in terms of range of motion,” and the VA examiner’s stated reason for declining to provide an estimate was: “Would be mere speculation, since exam is not performed in that circumstance.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court addressed the adequacy of medical opinions that decline to present clear estimations by citing that such estimations would be mere speculation. The Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion regarding functional loss. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. The Board finds that a new examination is warranted to support adequately informed appellate review and to comply with the decision in Sharp. Additionally, the Board notes that the April 2017 VA examination report indicates that “Yes,” there was “evidence of pain on passive range of motion testing.” (The VA examiner expressed some uncertainty as to whether the pain was “clearly ANKLE pain,” but ultimately responded in the affirmative to the question on the ankle examination form regarding pain on passive range of motion.) The April 2017 VA examination report generally addresses both the right and left ankles, usually with specific findings for each joint, but this finding of “evidence of pain on passive range of motion testing” does not specify which ankle or ankles are being described. Assuming, in light of the ambiguity, that the left ankle is implicated by the notation of evidence of pain on passive range of motion testing, appellate review must make a determination as to the extent of functional impairment associated with the noted pain. However, the notation of “evidence of pain on passive range of motion testing” is not accompanied by any description of presence or absence of associated functional impairment. There is not otherwise any information presented in the report that might inform an understanding of functional impairment due to the referenced pain, as the VA examiner found no evidence of pain on other forms of range of motion testing in earlier sections of the VA examination report. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. One potential interpretation of the final sentence of 38 C.F.R. § 4.59 (“The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing…”) is that the information provided by the April 2017 VA examination report is sufficient with regard to Correia. This is true, the argument continues, because the text of the regulation requires only that the examiner test for pain and the examiner in this case has done that by indicating whether or not the Veteran experienced pain during range of motion testing using the required methods. But there are several parts of the opinion in Correia that suggest that it is not enough merely to indicate whether or not pain was present during a test. In the part of the decision that considered whether § 4.59 was ambiguous, the Court explained the role of the regulation in the context of other regulations which apply generally to disabilities of the musculoskeletal system. “In that context, then, we read the final sentence of § 4.59 as explaining the kinds of test results that ‘should’ be obtained to permit an adjudicator to assess the effect of painful motion - range of motion tests for both passive and active motion, and in both weight-bearing and non-weight-bearing circumstances.” Correia, 28 Vet. App. at 165 (emphasis in original). It is difficult to see how test results which merely indicate the presence or absence of pain would permit an adjudicator to assess the -effect- of pain on range of motion. To do so effectively, it would be useful for the adjudicator to have the full results of each range of motion test, i.e., the range of motion, in degrees, of the relevant joint using each of the testing methods identified in the regulation. The Correia opinion continues with analysis of the proper interpretation of § 4.59. This part of the Court’s analysis indicates that the regulation should be read together with 38 C.F.R. §§ 4.40 and 4.45. The Court explained that: [§ 4.40] states that it “is essential” that an examination on which a disability rating is based “adequately portray the anatomical damage[] and the functional loss” that occurs as a result of those elements. Section 4.45 explains that “the factors of [joint] disability reside in reductions of their normal excursion of movements in different planes,”.... Neither of those regulations, however, explains how that information should be obtained, except that § 4.40 refers to “an examination,” but the Secretary has answered this question in § 4.59. Correia, 28 Vet. App. at 169 (internal short form citations and explanatory parenthetical omitted) (emphasis in original). If § 4.59 was intended to accomplish the purposes of § 4.40 and § 4.45, one of which is to assess “reductions of [the] normal excursion of movements [of the joint] in different planes,” the most reasonable reading of § 4.59 requires the examiner to provide detailed range of motion test results, not merely an indication of whether or not pain was present. The final sentence the Court’s regulatory interpretation analysis supports this conclusion: “Consequently, we are left with the inescapable conclusion that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Id. at 169-70. The April 2017 VA examination report does not provide the test results or data necessary for the Board to assess the degree of such functional impairment in the left ankle. There is the problem of the ambiguity as to whether the left ankle is even involved in the finding of pain on passive range of motion testing. There is furthermore an absence of any indication of the portion of the range of motion affected by the noted pain, or the degree of limitation due to pain, from testing that was directly conducted/observed by the VA examiner. These problems prevent the Board from making a meaningfully informed determination as to the severity of the functional loss that has been indicated by the VA examiner’s findings and comments. The Board finds that clearer and more adequate descriptions of the functional loss due to pain on passive range of motion testing would be important to informed appellate review. As the Board has already determined that a new VA examination is necessary to provide the information necessary in accordance with the holding of the United States Court of Appeals for Veterans Claims (Court) in Sharp, the Board shall additionally request that the new VA examination report support adequately informed appellate review by providing the information necessary to comply with the decision in Correia v. McDonald, 28 Vet. App. 158 (2016). 2. The issue of entitlement to a rating in excess of 10 percent for allergic rhinitis with chronic sinusitis is remanded. The Veteran seeks an increased compensable rating for her service-connected allergic rhinitis with chronic sinusitis. This disability is rated under the provisions of 38 C.F.R. § 4.97, Diagnostic Code 6513. Under this Diagnostic Code, the Veteran’s claim of entitlement to an increased compensable rating depends, in pertinent part, upon a showing that the disability manifests in at least three incapacitating episodes per year requiring at least four weeks of antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A note in the provisions of the Diagnostic Code explains that “An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician.” The Board notes that the Veteran’s most recent VA “Sinusitis, Rhinitis” examination for rating purposes in this case was conducted four years ago, in July 2016. Evidence from after this VA examination suggests that the Veteran is now experiencing pertinent manifestations of her service-connected rhinitis / sinusitis disability that are more severe, including with indications of incapacitating episodes, than the symptom picture documented at the time of the July 2016 VA examination. Specifically, the July 2016 VA examination report shows that the VA examiner found that the Veteran had, as of that time, -not- experienced any incapacitating episodes of sinusitis requiring bed rest and treatment by a physician. Subsequent medical evidence from the 4 years that have passed since that examination include, for instance, a June 21, 2019, VA medical report showing that the Veteran sought treatment for “sinus congestion/pres[s]ure and cough … has headaches and has been bringing up yellow sputum” and that she believed that her “constant post nasal dc” was causing her “sore[]throat” and “constant cough.” Medical assessment noted “ch[ronic] sinusitis” and the Veteran was prescribed antibiotics (”will start on zpack”); additionally, the treating medical doctor specifically noted that the Veteran was “advised to rest” in addition to “keep beside humidifier.” This report came after the Veteran had previously sought treatment on June 3, 2019, for “nasal and sinus congestion … and has post nasal dc, facial pain esp[ecially] the l[ef]t cheek area, blowing clear phlegm, has headaches and seems sinuses are blocked along with the nasal passages.” The Board notes that July 2018 and July 2017 VA treatment reports show substantially identical symptomatology, and note that “ct of sinuses in 8/2016 showed 1. Probable mucus retention cyst right maxillary sinus,” among other findings. The Board finds that the sinus symptoms together with the medical treatment, physician-advised “rest,” and prescription antibiotic treatment suggest greater symptomatology than was identified / reported / contemplated at the time of the most recent July 2016 VA examination report four years ago. The evidence from the intervening 4 years since the VA examination now describes manifestations that may newly meet the criteria to be considered “incapacitating” (requires bed rest and treatment by a physician) in contrast to the July 2016 VA examiner’s finding of no such episodes. This medically documented indication of incapacitating episodes suggests a worsening of the disability, but is not accompanied by sufficiently clear or specific evidence for the Board to determine the number and duration of qualifying incapacitating episodes per year, or even the number and duration of non-incapacitating episodes per year (which could also potentially qualify for higher ratings) now associated with the worsening disability. To provide adequate consideration of the Veteran’s claim, the Board finds that a new VA examination is warranted to provide the updated data and findings necessary to support an informed appellate review of this rating issue on appeal. VA’s General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). The Board finds that a new VA examination is warranted to assess the current severity of the Veteran’s rhinitis / sinusitis disability. 3. The issue of entitlement to a total disability rating based on individual unemployability TDIU is remanded. Pending development on the remanded rating issues could significantly impact a decision on the issue of entitlement to a TDIU. Accordingly, the issues are inextricably intertwined. A remand of the issue of entitlement to a TDIU is required. The Court has held that two issues are inextricably intertwined when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, the Board must defer final adjudication of the claim seeking TDIU until the development concerning her reported increased severity of service-connected disabilities has been completed. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disorders remaining on appeal. Please ask the Veteran to provide the releases necessary for VA to secure any adequately identified private treatment records that the Veteran may wish VA to assist her in obtaining for the record. 2. After the record is determined to be complete, schedule a VA examination to ascertain the severity of the Veteran’s service-connected left ankle disability. The claims-file must be made available to, and be reviewed by, the examiner. All indicated testing should be accomplished and all symptomatology associated with the left ankle disability should be identified. In addition to all findings identified on the appropriate examination forms, the VA examiner should determine the effective ranges of motion of the left ankle, and address each of the following items: (a) Please provide a copy of your curriculum vitae as part of the VA examination report. (b) The examiner’s report should reflect range of motion tests in a written report by recording separate sets of the range of motion test results for both active and passive motion, in weight bearing and nonweight-bearing (to the extent applicable), and, if possible, in comparison to the opposite, undamaged, joint (to the extent applicable). (c) The examiner should describe objective evidence of painful motion, if any, during each test. It is not sufficient merely to indicate whether or not pain was present during one of the required range of motion tests. If any of these findings are not possible, please provide an explanation. (d) The examiner is also asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The Board is not permitted to accept a rationale that the examiner is unable to offer an opinion without resort to speculation based on an aversion to offering an opinion on issues not directly observed. 3. After the record is determined to be complete, schedule a VA examination to ascertain the current severity of the Veteran’s service-connected rhinitis / sinusitis disability. The VA examiner is asked to please provide a copy of his/her curriculum vitae as part of the VA examination report. The Veteran’s entire record should be reviewed by the examiner in connection with the examination. The examiner must include a rationale with all opinions. The VA examiner is specifically requested to discuss as necessary the recent VA medical records (including those dated in June 2019 showing that the Veteran’s rhinitis / sinusitis has now manifested in episodes medically treated with physician prescribed antibiotics and prescribed “rest”) when determining the number and duration of incapacitating episodes and non-incapacitating episodes the Veteran experiences per year. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the inextricably intertwined issue of entitlement to a TDIU. If any benefit sought on appeal is not granted to the Veteran’s satisfaction, send the Veteran a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barone, 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.