Citation Nr: 21003556 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 12-22 566 DATE: January 21, 2021 ORDER Entitlement to an effective date earlier than December 18, 2009 for service connection for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is denied. Entitlement to an evaluation in excess of 10 percent prior to November 24, 2014 for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is denied. Entitlement to an evaluation in excess of 20 percent prior to February 22, 2016 for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is denied. Entitlement to an evaluation in excess of 40 percent prior to November 13, 2019 for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is denied. Entitlement to an initial compensable disability rating for erectile dysfunction associated with Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is denied. REMANDED Entitlement to service connection for back condition is remanded. FINDINGS OF FACT 1. The Veteran first filed a claim for service connection for Reiter's syndrome on September 18, 1973. The claim was denied in a November 1983 Board decision, which is final. 2. The Veteran filed a claim to reopen service connection for Reiter’s syndrome on September 23, 2002. This claim was denied in a February 2003 rating decision. He submitted a request to reopen the claim on June 2, 2003. This claim was again denied in a July 2003 rating decision. The Veteran appealed the July 2003 rating decision on June 30, 2004. The claim was denied in a September 2004 Statement of the Case. The Veteran did not appeal this decision or submit any evidence within one year of the decision, and it therefore became final. 3. The Veteran filed a claim to reopen service connection for Reiter’s syndrome on December 18, 2009. A February 2019 rating decision implemented a July 2017 Board grant of service connection for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, with an evaluation of 10 percent disability rating, effective December 18, 2009 (date of claim). 4. For the period from December 18, 2009 to November 23, 2014, the Veteran’s Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, was manifested by daytime voiding interval between two and three hours and awakening to void two times per night. 5. For the period from November 24, 2014 to February 21, 2016, the Veteran’s Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, was manifested by daytime voiding interval between one and two hours. 6. For the period from February 22, 2016 to November 12, 2019, the Veteran’s Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, was manifested by the wearing of absorbent materials which must be changed two to four times per day and daytime voiding interval less than one hour. 7. Since November 13, 2019, the Veteran’s Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, has been manifested by the wearing of absorbent materials which must be changed more than four times per day. 8. For the entire period on appeal, the Veteran’s erectile dysfunction associated with Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, has not been manifested by penile deformity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date earlier than December 18, 2009 for service connection for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.310, 3.400. 2. The criteria for entitlement to an evaluation in excess of 10 percent prior to November 24, 2014 for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.115a, Diagnostic Code 7518. 3. The criteria for entitlement to an evaluation in excess of 20 percent prior to February 22, 2016 for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.115a, Diagnostic Code 7518. 4. The criteria for entitlement to an evaluation in excess of 40 percent prior to November 13, 2019 for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.115a, Diagnostic Code 7518. 5. The criteria for an initial compensable disability rating for erectile dysfunction associated with Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy, have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.115b, Diagnostic Code 7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1967 to June 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of May 2010 and February 2019 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the matter from the May 2010 rating decision in July 2017 for further development. It has since been returned to the Board for appellate review. During the pendency of this appeal, the disability rating evaluation of 40 percent for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy was granted an earlier effective date of February 22, 2016, in a March 2020 rating decision. The March 2020 rating decision also granted a 60 percent disability rating evaluation effective November 13, 2019. 38 C.F.R. § 4.115a, Diagnostic Code 7518. The Board notes that the Veteran submitted a VA Form 21-22a appointing the listed attorney as his representative in July 2020; however, the representative’s signature was missing from the document and it could not be accepted because it was incomplete. VA sent the Veteran a letter dated November 17, 2020 advising him that the VA Form 21-22a he submitted in July 2020 was incomplete and that the listed attorney would not be recognized as his representative until VA receives a properly executed VA Form 21-22a from the Veteran. The Veteran submitted a properly executed VA Form 21-22a in December 2020. Therefore, the Board recognizes the listed attorney as the Veteran’s representative for this matter. Neither the Veteran nor his representative has raised any other issued, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). 1. Entitlement to an effective date earlier than December 18, 2009 for service connection for Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status port urethral bypass/urethrectomy The effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection on a direct basis, shall be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service. Otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). For VA compensation purposes, a “claim” is defined as “a written communication requesting a determination of entitlement or evidencing a belief in entitlement, to a specific benefit under the laws administered by the Department of Veterans Affairs submitted on an application form prescribed by the Secretary.” 38 C.F.R. § 3.1(p). An informal claim is “[a]ny communication or action indicating an intent to apply for one or more benefits.” 38 C.F.R. § 3.155(a). It must “identify the benefit sought.” Id. Thus, the essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim, both formal and informal, for benefits and is required to identify and act on informal claims for benefits. See Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). The Veteran first submitted an application for entitlement to service connection for Reiter’s syndrome in September 1973. The Veteran’s claim was denied in a rating decision issued in January 1974. The Veteran appealed the January 1974 rating decision, and the claim was later denied in a November 1983 Board decision. The Veteran again filed an application for entitlement to service connection for Reiter’s syndrome in in September 2002 and was denied in a February 2003 rating decision. Although the Veteran did not appeal the February 2003 rating decision, he did submit a request to reconsider the claim in June 2003. See VA Form 9, received by VA in June 2003. The claim was again denied in a July 2003 rating decision issued pursuant to the June 2003 request to reconsider. The Veteran appealed the July 2003 rating decision in a timely manner and was denied a September 2004 Statement of the Case. The November 1983 Board decision and the September 2004 Statement of the Case were not appealed by the Veteran and became final. The Veteran submitted a request to reopen the claim for entitlement to service connection for Reiter’s syndrome which was received on December 18, 2009. The July 2017 Board decision found that new and material evidence warranted reopening of the claim and granted entitlement to service connection for Reiter’s syndrome. In a February 2019 rating decision, the Veteran was assigned an evaluation of 10 percent with an effective date of December 18, 2009. The earliest date after September 2004 that the Veteran expressed an intent to reopen his claim for service connection for Reiter’s syndrome is December 18, 2009, which is presently the effective date. Under the controlling law and regulations outlined above, the award of compensation based on a reopened claim may be no earlier than the date of the receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2). Accordingly, the Board finds that the December 18, 2009 date of the claim is the appropriate effective date, because, even if the date that the entitlement arose could be found to precede it, the latter of the two dates controls 38 C.F.R. § 3.400. The claim for an earlier effective date must be denied. See 38 C.F.R. § 3.400(q)(2), see also Washington v. Gober, 10 Vet. App. 391, 393 (1997); Wright v. Gober, 10 Vet. App. 343, 346-47 (1997). Increased Rating for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran is in receipt of a 10 percent rating for his Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy for the period prior to November 24, 2014; a 20 percent rating for the period from November 24, 2014 to February 21, 2016; a 40 percent rating for the period from February 22, 2016 to November 12, 2019; and a 60 percent rating (tbe maximum for urinary disability without renal involvement) beginning November 13, 2019. The disability is rated under 38 C.F.R. § 4.115a, Diagnostic Code 7518, which contemplates stricture of the urethra. That code directs that the disability be rated as a voiding dysfunction. He asserts that his service-connected Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy is more severe than is reflected by his current staged ratings. Voiding dysfunction is rated based upon urine leakage, frequency, or obstructed voiding. Urine leakage contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. A 20 percent rating for urine leakage contemplates the wearing of absorbent materials, which must be changed less than two times per day. A 40 percent rating is warranted for the wearing of absorbent materials, which must be changed two to four times per day. A maximum disability rating of 60 percent is warranted for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a. For a rating based on urinary frequency, a 10 percent rating is warranted for a daytime voiding interval between two and three hours, or awakening to void two times per night. A 20 percent rating is warranted where there is a daytime voiding interval between one and two hours, or awakening to void three to four times per night. A maximum rating of 40 percent is warranted for a daytime voiding interval of less than one hour, or awakening to void five or more times per night. 38 C.F.R. § 4.115a. Ratings are also provided based upon obstructed voiding and urinary tract infection, but the Veteran has not required intermittent or continuous catheterization for obstruction (as would warrant a 30 percent evaluation) and has not reported recurrent urinary tract infections. The Veteran was first afforded a VA examination for his Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy in November 2014. The Veteran reported that his voiding dysfunction caused daytime voiding interval between one and two hours and nighttime awakening to void two times. He further reported that his voiding dysfunction caused urine leakage which did not require the wearing of absorbent material or the use of an appliance. The examination report noted that the Veteran’s voiding dysfunction did not cause signs or symptoms of obstructed voiding and that there were no other obstructive symptoms. The Veteran was next afforded a VA examination in July 2016. The Veteran reported that his voiding dysfunction required absorbent material which must be changed two to four times per day. He further reported that his voiding dysfunction caused daytime voiding less than one hour and nighttime awakening to void two times. The examination report noted that the Veteran’s voiding dysfunction did not require the use of an appliance and that it did not cause signs or symptoms of obstructed voiding. The Veteran was afforded an additional VA examination in November 2019. The Veteran reported that his voiding dysfunction required absorbent material which must be changed more than four times per day. He further reported that his voiding dysfunction caused daytime voiding less than one hour and nighttime awakening to void two times. The examination report noted that the Veteran’s voiding dysfunction did not require the use of an appliance and that it did not cause signs or symptoms of obstructed voiding. VA and private medical treatment records indicate that the Veteran was experiencing urine leakage and obstructive voiding symptoms caused by his Reiter’s as early as November 2004. See CAPRI, received by VA in Medical Treatment Record – Non-Governmental Facility, received by VA in May 2010; Correspondence, received by VA in May 2010. A VA treatment record dated February 22, 2016 shows that the Veteran’s nighttime voiding has increased and that he experiences enuresis on a nightly basis. He also reported daytime urge incontinence and the use of “pull-ups” during the day. See CAPRI, received by VA in November 2017. Prior to November 24, 2014, the preponderance of the evidence is against a finding that the Veteran’s Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy was manifested by symptoms warranting a 20 percent rating evaluation, as the evidence does not show the wearing of absorbent materials which must be changed less than two times per day; daytime voiding interval between one and two hours, or; awakening to void three to four times per night. Accordingly, an increased rating greater than 10 percent for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy prior to November 24, 2014 is not warranted. Regarding the period from November 24, 2014 to February 21, 2016, the preponderance of the evidence is against a finding that the Veteran’s Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy was manifested by symptoms warranting a 40 percent rating evaluation, as the evidence does not show the wearing of absorbent materials which must be changed two to four times a day; daytime voiding interval less than one hour, or; awakening to void five or more times per night. The Board notes that Veteran’s Reiter’s symptoms prior to February 22, 2016 fall within the 20 percent rating. Specifically, the Veteran’s urine frequency was manifested by daytime voiding interval between one and two hours. The Veteran’s urine leakage was not so severe that it required the wearing of absorbent material. Consequently, an increased rating greater than 20 percent for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy prior to February 22, 2016 is not warranted. Regarding the period from February 22, 2016 to November 12, 2019, the preponderance of the evidence is against a finding that the Veteran’s Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy was manifested by symptoms warranting a 60 percent rating evaluation, as the evidence does not show the wearing of absorbent materials which must be changed more than four times per day. The Board notes that Veteran’s Reiter’s symptoms prior to November 13, 2019 fall within the 40 percent rating. Specifically, the Veteran’s urine frequency was manifested by daytime voiding interval less than one hour and the wearing of absorbent material which must be changed two to four times per day. Therefore, an increased rating greater than 40 percent for Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy prior to November 13, 2019 is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in this appeal. 38 U.S.C. § 5107(b). 2. Entitlement to an initial compensable disability rating for erectile dysfunction associated with Reiter's syndrome with recurrent urethral strictures; urinary incontinence; status post urethral bypass/urethrectomy The Veteran’s erectile dysfunction associated with Reiter’s syndrome with recurrent urethral strictures; urinary incontinence; status port urethral bypass/urethrectomy, is currently rated as noncompensable from December 18, 2009 under Diagnostic Code 7522, regarding an unlisted disability of the genitourinary system rated by analogy to deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Thereunder, in order to warrant an increased 20 percent disability rating for erectile dysfunction, physical deformity of the penis with loss of erectile power is required. As “deformity” is not defined in the rating criteria, the term is given its ordinary meaning. In medical terminology, a “deformity” is a distortion of any part or general disfigurement of the body. See Dorland’s Illustrated Medical Dictionary 478 (32nd ed. 2012). A synonym for “deformity” is “misshapen.” See Webster’s New College Dictionary 718 (3d ed. 2008). A footnote to Diagnostic Code 7522 also indicates the disability is to be reviewed for entitlement to special monthly compensation (SMC) for loss of use of a creative organ under 38 C.F.R. § 3.350(a); however, the Board notes that the Veteran is already in receipt of SMC for loss of use of a creative organ. Following a review of the evidence of record, the Board finds that preponderance of the evidence weighs against the Veteran’s claim of entitlement to a compensable initial disability rating for erectile dysfunction for the entire period on appeal. In a VA treatment record from November 2004, the Veteran reported that he underwent a surgery to implant a small Carion penile prosthesis in 1984 to treat his erectile dysfunction. The Veteran also expressed a desire to have his penile implant removed because he attributed as being the cause of multiple urinary tract infections he has had since he had the penile prosthesis implanted. However, he never had his penile implant removed. Upon examination in November 2014, the Veteran reported that he had a total urethrectomy and perineal urethrostomy in the 1970s due to voiding problems associated with his Reiter’s syndrome. After these surgeries, the Veteran stated that he developed erectile dysfunction. The Veteran also reported that he is unable to achieve an erection sufficient for penetration and ejaculation with or without medication. The Board finds that the objective evidence of record clearly shows a loss of erectile power. However, in order to obtain a compensable rating under Diagnostic Code 7522, deformity of the penis must also be demonstrated. Significantly, the probative evidence of record does not document any subjective complaint, medical treatment, or objective findings of penile deformity for any period on appeal. To the extent that it could be argued that the Veteran’s penile implant qualified as a deformity for rating purposes, the Board notes that none of the objective evidence documents that the Veteran’s penis is actually deformed. Furthermore, with respect to VA benefits, as noted above, SMC for loss of use of a creative organ was previously granted to compensate the Veteran for his erectile dysfunction. Consequently, the Board finds that the preponderance of the evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for back condition is remanded. In July 2017, the Board remanded the claim to afford the Veteran a VA back conditions examination to determine the nature and etiology of his lumbar spondylosis with degenerative disc disease, including whether it casually related to a service-connected disability, including Reiter’s syndrome. The Veteran was afforded a VA examination for his back condition in November 2019. The Veteran reported that his back pain started in 1999, without history of an injury. He explained that he was working in a construction at the time and had pain in his low back. The examiner noted the Veteran was diagnosed with intervertebral disc syndrome in 2010. The examiner further noted that the Veteran had fleeting joint pain in his back, left shoulder, and both knees of varying intensity, but the examiner did not provide an etiology opinion as to the cause of the Veteran’s back condition. The Veteran was next afforded a VA examination for his back in January 2020. The examiner diagnosed the Veteran with spinal stenosis, lumbar dextrorotoscoliosis, osteoarthritis with degenerative disc disease, and radiculopathy of the bilateral lower extremities. The Veteran reported that his back pain started in 1978. He said he developed the back pain without any specific injury or event and that he continued to have back pain off and on after that, with the pain getting progressively worse. The examiner opined that the Veteran’s back condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. For rationale, the examiner noted there were no service treatment records noting complaints, treatment, or diagnosis of lumbar spine condition. He said there was not sufficient evidence to support the claimed lumbar spine disorder/lumbar spondylosis with degenerative disc disease was at least as likely as not (50 percent or greater probability) incurred in or caused by the Veteran’s period of active service or otherwise etiologically related to his active service. The examiner also opined that the Veteran’s back condition was less likely than not (less than 50 percent probability) proximately due to or the result of one or more of the Veteran’s service-connected conditions, to include Reiter’s syndrome. The examiner explained that there was not sufficient evidence to support the claimed lumbar spine disorder/lumbar spondylosis with degenerative disc disease was at least as likely as not (50 percent or greater probability) proximately due to or caused by the Veteran’s service-connected disabilities. He stated that reactive arthritis, formerly known as Reiter’s syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). The examiner explained that coming into contact with bacteria and developing an infection can trigger the disease; however, the Veteran was not diagnosed with an inflammatory condition; he was diagnosed with osteoarthritis with degenerative disc disease. The examiner further opined that he could not determine a baseline level of severity of the Veteran’s back condition based upon medical evidence available prior to aggravation or the earliest medical evidence available prior to aggravation or the earliest medical evidence following aggravation or the earliest medical evidence following aggravation by one or more of the Veteran’s service-connected disabilities, to include Reiter’s syndrome. The examiner explained that a baseline cannot be established because there was not sufficient evidence to support that the claimed lumbar spine disorder/lumbar spondylosis with degenerative disc disease was at least as likely as not aggravated beyond its natural progression by one or more of the Veteran’s service-connected disabilities. The examiner further opined that regardless of an established baseline, the Veteran’s back condition was less likely than not aggravated beyond its natural progression by one or more of the Veteran’s service-connected disabilities. As rationale, the examiner explained that there was not sufficient evidence to support that the claimed lumbar spine disorder/lumbar spondylosis with degenerative disc disease was at least as likely as not aggravated beyond its natural progression by one or more of the Veteran’s service-connected disabilities. The Board finds the January 2020 medical opinion to be inadequate because the examiner’s rationale did not discuss the actual cause of the Veteran’s back pain. The Board particularly finds the aggravation opinion to be conclusory. Moreover, the examiner did not specifically address all the diagnosed back conditions in the medical opinion. Accordingly, a remand is warranted to obtain a new medical opinion that fully addresses the etiology of the Veteran’s low back condition. The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records in accordance with duties set forth in 38 C.F.R. § 3.159(c). 2. After obtaining any outstanding records, forward the Veteran’s claims file to a qualified medical professional to obtain an addendum opinion as to the nature and etiology of the Veteran’s back disability. After reviewing the record, the examiner is asked to address the following: (a.) Provide a current diagnosis for any back condition that manifested during the period on appeal (December 2009 – present). The diagnoses include, but not limited to, intervertebral disc syndrome, spinal stenosis, lumbar dextrorotoscoliosis, osteoarthritis with degenerative disc disease, and radiculopathy of the bilateral lower extremities. (b.) If the Veteran does not now have, but previously had, any diagnosed disorder, indicate when that disorder resolved; and (c.) For each disorder diagnosed during the appellate period, is it at least as likely as not (50 percent or greater probability) that the Veteran’s currently (or previously) diagnosed back disability is causally related to his active service? If it is less likely that the Veteran’s current (or previous) back disability is related to his active service, the examiner should discuss why this is the case, with full consideration of the Veteran’s own reported history. The examiner is specially asked to address the Veteran’s reports that his back pain began while working a job in construction in 1999. See CAPRI entry dated July 8, 1999, received by VA in March 2016; and the November 1999 VA examination for back conditions. (d.) For each disorder diagnosed during the appellate period, is it at least as likely as not (50 percent or greater probability) that the Veteran’s currently (or previously) diagnosed back disability is proximately due to or aggravated by one or more of the Veteran’s service-connected disabilities, notably Reiter’s syndrome? The examiner should note that the term “aggravated by” refers to a chronic or permanent worsening of the underlying condition, as contrasted to mere temporary or intermittent flare-ups of symptoms that resolve and return to the baseline level of disability. If the opinion is that one or more service-connected disabilities aggravated the Veteran’s currently (or previously) diagnosed back disability, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. The examiner must provide a complete rationale for any opinion expressed. Particularly with regard to the requested aggravation opinion, a detailed rationale with reference to medical literature, as appropriate, would be helpful. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fairlie, 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.