Citation Nr: 21003698 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 12-17 487A DATE: January 22, 2021 ORDER Entitlement to a 10 percent rating based on multiple noncompensable service-connected disabilities is denied. REMANDED Entitlement to service connection for uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for a miscarriage, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. Entitlement to service connection for anemia, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. Entitlement to service connection for fibrocystic breast disease, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for a gastrointestinal disorder, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for fibromyalgia, body and muscle aches, and fatigue, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for a skin disability, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for a headache disability, claimed as an undiagnosed illness, is remanded. Entitlement to service connection for allergic rhinitis, nasal congestion, and sinus symptomatology, claimed as an undiagnosed illness, is remanded. Entitlement to an initial compensable rating higher for a bilateral eye disability is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the right foot is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the left foot is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the right hand is remanded. Entitlement to a rating higher than 10 percent for frostbite residuals in the left hand is remanded. FINDING OF FACT The Veteran has had compensable service-connected disabilities for the appeal period. CONCLUSION OF LAW The criteria for a 10 percent rating based on multiple noncompensable service-connected disabilities are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.1, 3.102, 3.324. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1984 to February 1987, and November 1988 to December 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In February 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In September 2017, the Board remanded the case for further development. 1. Entitlement to a 10 percent rating based on multiple noncompensable service-connected disabilities A veteran with two or more separate and permanent service-connected disabilities of such character as to clearly interfere with normal employability, even though none of the disabilities may be of compensable degree under the rating schedule, may be assigned a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. The Veteran has a combined service-connected disability rating of 90 percent as of October 14, 2009. There are no pending claims for service connection prior to October 14, 2009. There are no pending claims for effective dates for service connection for any disability prior to October 14, 2009. A 10 percent rating under 38 C.F.R. § 3.324 may not be combined with any other rating. Therefore, as the Veteran has compensable service-connected ratings for the entire period for which service connection has been established for any disability, she cannot be assigned a 10 percent rating for multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324, and the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, claimed as an undiagnosed illness, is remanded. The Veteran testified that painful menstruation began during service. Her cysts started during service, and they were discovered a few years after separation. The cysts led to the hysterectomy. Hearing transcript, p. 19-20. In a January 2018 VA examination, the Veteran reported that her fibroids were first diagnosed around 1995 and she had clots during menstruation. The examiner noted that there was no evidence in the service medical records that showed the Veteran was diagnosed with uterine fibroids during service. The examiner concluded that the fibroids were less likely than not incurred in or caused by service. In an August 2020 medical opinion, the same VA examiner explained that while the Veteran’s menstrual symptomatology was credible, it was not possible to say that the 2009 surgical fibroid removal was attributed to those symptoms with 100 percent accuracy. In addition, the examiner noted that the Veteran most likely had routine gynecological visits during service that did not diagnose the fibroids. The examiner concluded that the fibroids were less likely than not incurred in or caused by service. The September 2017 Board remand instructed the examiner to accept the Veteran’s report of in-service menstrual symptomatology as credible. The January 2018 and August 2020 opinions are incomplete. The January 2018 opinion found no evidence of a diagnosis during service. However, the remand instructed the examiner to accept the Veteran’s report of in-service menstruation symptomatology as credible. The August 2020 opinion applied the incorrect standard of law. The examiner found that the fibroid removal could not be attributed to the Veteran’s in-service menstrual symptomatology with 100 percent accuracy. The standard is at least as likely as not, which means more than 50 percent. For these reasons, the Board finds the January 2018 and August 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 2. Entitlement to service connection for a miscarriage, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. The Veteran contends that her miscarriage in 1995 was related to in-service menstruation irregularities and cyst. Hearing transcript, p. 23. In a January 2018 opinion, the examiner provided a negative opinion for the miscarriage disability. The examiner explained that any opinion would be speculative and outside of the examiner’s scope of practice. In addition, there were no medical provider notes documenting an etiology. While examiner noted that an opinion would be speculative, the response did not indicate that an opinion was unable to be rendered. As the examiner was unable to provide an opinion because the knowledge was outside of the examiner’s practice, the Board finds an additional opinion is necessary. 3. Entitlement to service connection for anemia, claimed as an undiagnosed illness and as secondary to uterine fibroids with painful menstruation, abdominal hysterectomy, and residual abdominal scar, is remanded. The Veteran reported that she was diagnosed with anemia when she was pregnant during service and continues to receive treatment for anemia. Hearing transcript, p. 29-31. The January 2018 VA examination showed a diagnosis for anemia. The Veteran reported nausea and tiredness. The examiner provided a negative opinion for direct service connection because there was no evidence to show a diagnosis during service. In an August 2020 opinion, the examiner found that anemia was not caused or aggravated by the Veteran’s fibroids or hysterectomy. No rationale was provided. In the September 2017 remand, the Board requested an opinion on whether any anemia that the Veteran had since October 2009 had its onset during service. In addition, the examiner was instructed address whether any anemia was caused or aggravated uterine fibroids or current residuals of a hysterectomy. The January 2018 and August 2020 opinions did not offer complete rationale and did not take the Veteran’s lay statements into consideration. For these reasons, the Board finds the January 2018 and August 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 4. Entitlement to service connection for fibrocystic breast disease, claimed as an undiagnosed illness, is remanded. The Veteran reported that she had lumpy breasts during service and continues to receive treatment for fibrocystic breast disease. Hearing transcript, p. 27-28. The January 2018 VA examination showed a diagnosis for fibrocystic breast disease. The Veteran reported getting mammograms and have cysts drained after service. The examiner provided a negative opinion for fibrocystic breast disease because there was no evidence in the service medical records or available medical records that the disability began during service. In an August 2020 opinion, the examiner explained that it was not possible to state the diagnosis for fibrocystic breast disease in 2009 could be attributed to the Veteran’s reported symptoms with 100 percent accuracy. Given that the Veteran most likely had routine examination visits during service and the fibrocystic breast disease was not diagnosed, the examiner concluded that it was less likely than not that the breast disability can be attributed to service and developed after service. The Board finds the January 2018 and August 2020 VA opinions are incomplete. In the September 2017 remand, the Board requested an opinion on whether the Veteran’s breast disability was related to service. The Board instructed the examiner to accept the Veteran’s in-service breast symptomatology as credible. At the February 2017 Board hearing, the Veteran testified that she had lumpy breasts during service. Hearing transcript, p. 28. The January 2018 VA opinion did not consider the Veteran’s lay statements. The August 2020 opinion applied the incorrect standard of law. The examiner found that the fibrocystic breast disease could not be attributed to the Veteran’s in-service credible symptomatology with 100 percent accuracy. The standard is at least as likely as not, which means more than 50 percent. For these reasons, the Board finds the January 2018 and August 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 5. Entitlement to service connection for a gastrointestinal disorder, claimed as an undiagnosed illness, is remanded. The Veteran contends that her irregular bowels began during service. Hearing transcript, p. 24-26. The January 2018 VA examination showed reported symptomatology of diarrhea and vomiting. The examiner did not render any diagnoses. In a January 2018 VA opinion, the examiner provided a negative opinion for a gastrointestinal disability and irritable bowel syndrome (IBS). The examiner stated there was no medical evidence in the service medical records to support a diagnosis for IBS. Further, the available service medical records and current medical records, the Veteran’s gastrointestinal symptoms did not correspond with a known diagnosis. In a May 2020 opinion, the examiner stated that the Veteran’s claimed IBS was unrelated to stomach virus or gastrointestinal disabilities. The conditions resolved and did not continue after service. Further, there were no medical notes available to support an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknow etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. In an August 2020 opinion, the examiner explained that symptoms of diarrhea and vomiting are not specific to IBS or to Gulf War syndrome, and that they can occur frequently in a number of diagnosable conditions. Further there was no evidence that the symptoms were worked up by a medical provider and attributed to a diagnosis of IBS. The Board finds the January 2018, May 2020, and August 2020 VA opinions incomplete. In the September 2017 remand, the Board requested an opinion on whether the Veteran had irritable bowel syndrome and the etiology of any gastrointestinal symptomatology not attributable to IBS, including comments on whether it was a known clinical diagnosis. The examiner was also instructed to comment if a disease or disability that caused the reported symptoms could not be identified. The January 2018 opinion stated there was no evidence in the Veteran’s service medical records. However, the May 2020 opinion found that there was evidence in the service medical records, but the conditions resolved in service. The August 2020 opinion explained that the Veteran’s symptomatology could be attributed to other medical conditions, but it did not provide any support or elaboration for that assertion. In addition, the examiner did not assess whether the Veteran’s symptomatology could be attributed to a disease or disability without a clinical diagnosis. For these reasons, the Board finds the January 2018, May 2020, and August 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 6. Entitlement to service connection for fibromyalgia, body and muscle aches, and fatigue, claimed as an undiagnosed illness, is remanded. The Veteran contends that her disability that is manifested by body and muscle aches, and fatigue began during service. Hearing transcript, p. 40-41. In a January 2018 VA examination, the Veteran reported developing headaches and becoming tired after returning from deployment. She also had pain in her arms, neck, and shoulders. The examiner found that the Veteran did not have any current findings, signs or symptoms attributable to fibromyalgia. The examiner noted that a review of the medical records did show any chronic fatigue condition. The examiner provided a negative opinion, and concluded the evidence did not support that the Veteran had a diagnosis for fibromyalgia. In a May 2020 opinion, the examiner stated that the Veteran’s claimed symptomatology of body aches, fatigue, muscle aches were not specific to fibromyalgia, and the symptoms could be attributed to numerous medical conditions. Further, the examiner noted that there were no medical notes available to support an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknow etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. No rationale was provided. The September 2017 Board remand instructed the examiner provide an opinion on the etiologies of the reported body aches, muscle aches, and fatigue. In addition, the Board requested an opinion on whether the symptoms were attributable to known clinical diagnoses. The examiner was directed to state if a disease or disability causing the reported symptoms could not be identified. The January 2018 opinion focused on whether the Veteran had a diagnosis for fibromyalgia or a chronic fatigue condition. The May 2020 opinion explained that the Veteran’s symptomatology could be attributed to other medical conditions, but it did not provide any support or elaboration for that assertion. In addition, the examiner did not assess whether the Veteran’s symptomatology could be attributed to a disease or disability without a clinical diagnosis. For these reasons, the Board finds the January 2018 and May 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 7. Entitlement to service connection for a skin disability, claimed as an undiagnosed illness, is remanded. The September 2017 Board remand directed that the Veteran be provided with a new examination and an opinion on whether the Veteran’s skin disability was related to service. While two new opinions were obtained, the Veteran was not provided with an examination to assess the skin disability. The Board notes that the May 2020 and August 2020 opinions provided negative opinions because there the Veteran’s service treatment records did not show a diagnosis for dermatitis. However, the September 2017 remand directives specifically instructed the examiner to accept the Veteran’s in-service skin symptomatology as credible. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, a remand is necessary for compliance with the September 2017 remand directives. 8. Entitlement to service connection for a headache disability, claimed as an undiagnosed illness, is remanded. The Veteran contends that her headaches began during service and occurred daily. Hearing transcript, p. 50-51. The January 2018 VA examination diagnosed migraine headaches with migraine variants. The Veteran reported that her headaches began around 1990. She experienced headaches three to four times per week. In a January 2018 opinion, the examiner provided a negative opinion for the headache disability. The examiner indicated that the Veteran had a diagnosis in service and a diagnosis after service. The examiner did not provide any rationale. In a May 2020 opinion, the examiner same stated that available evidence did not show documentation or treatment for any headache diagnosis. The September 2017 Board remand instructed the examiner to accept the Veteran’s report of in-service headaches as credible. The January 2018 and May 2020 opinions are contradictory and incomplete. While the January 2018 opinion acknowledges diagnoses during service and after service, the examiner’s opinions did offer any rationale for the negative opinions. However, the May 2020 opinion stated there was not a headache diagnosis. For these reasons, the Board finds the January 2018 and May 2020 opinions are incomplete. Given the inconsistencies and lack of rationale, the Board finds an additional opinion is necessary. 9. Entitlement to service connection for allergic rhinitis, nasal congestion, and sinus symptomatology, claimed as an undiagnosed illness, is remanded. 8. Entitlement to service connection for allergic rhinitis, nasal congestion, and sinus symptomatology, claimed as an undiagnosed illness, 6522 The Veteran contends that her allergies and nasal congestion began during service. Hearing transcript, p. 53-54. The January 2018 VA examination diagnosed rhinitis. The examiner provided a negative opinion for the sinus disability, because there was no evidence in the service treatment records or available medical records to support the claim of congestion or rhinitis. In an August 2020 opinion, the same examiner noted that the rhinitis condition was at least as likely as not incurred in or caused by congestion during service. However, the examiner continued that a positive opinion could be provided if the RO conceded the March 1991 service treatment record noting congestion was indicative of rhinitis. While the Board appreciates the examiner’s efforts, the opinions are incomplete. The September 2017 Board remand instructed the examiner to accept the Veteran’s report of in-service nasal congestion as credible. The January 2018 opinion did not accept the Veteran’s lay statement as credible. Although the August 2020 opinion was positive, it was not supported by rationale indicating a positive nexus between service and the current disability. For these reasons, the Board finds the January 2018 and August 2020 opinions are incomplete. On remand, the Board finds an additional opinion is necessary. 10. Entitlement to an initial compensable rating higher for a bilateral eye disability is remanded. The Veteran contends that the bilateral eye disability warrants a higher rating. The Veteran’s dry eye disability is rated noncompensable under Diagnostic Code 6080, which pertains to visual field impairments. An August 2011 private treatment record noted diagnoses for blepharitis, dry eyes, and conjunctivitis. The results of the February 2018 VA examination indicate the bilateral eye disability has manifested with bilateral pinguecula, conjunctivochalasis, and dry eye. The February 2018 VA examiner found that it was at least as likely as not that the Veteran’s dry eye symptomatology throughout the appeal period was explained by the diagnoses for bilateral pinguecula and conjunctivochalasis. While the examiner specifically stated that the conjunctivochalasis was not conjunctivitis, the examiner did not address the August 2011 diagnoses for blepharitis and conjunctivitis. On remand, an addendum opinion must be obtained to address the additional diagnoses. 11. Entitlement to a rating higher than 10 percent for frostbite residuals in the right foot is remanded. 12. Entitlement to a rating higher than 10 percent for frostbite residuals in the left foot is remanded. 13. Entitlement to a rating higher than 10 percent for frostbite residuals in the right hand is remanded. 14. Entitlement to a rating higher than 10 percent for frostbite residuals in the left hand is remanded. The Board notes that the RO has not issued a Supplemental Statement of the Case (SSOC) regarding the increased rating claims for frostbite residuals in the hands and feet. In an April 2020 rating decision, the RO granted a 10 percent rating for frostbite residuals in the right foot, left foot, right hand, and left hand. The Veteran’s claim for service connection for a right great toe rating was incorporated in the right foot rating. As the 10 percent disability ratings are not the maximum rating available for these disabilities, the claims remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from April 2019 to the present. 2. Obtain an opinion from an appropriate clinician to determine the nature and etiology of that any uterine fibroids and current residuals of hysterectomy. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that any uterine fibroids and current residuals of hysterectomy are related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of menstrual irregularities during service. The examiner must accept the Veteran’s reports of in-service menstruation symptomatology as credible. A complete rationale for all opinions expressed should be clearly provided. 3. Obtain an opinion from an appropriate clinician to determine the nature and etiology of any current disability that caused a miscarriage in 1995. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has any current disability that caused a miscarriage in 1995. If a current disability is identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the current disability had its onset during her periods of active service, or is related to any event or injury in service, to include serving in the Persian Gulf region. The examiner should also opine whether it is at least as likely as not (50 percent probability or greater) that the any current disability that caused a miscarriage was caused by the uterine fibroids or current residuals of a hysterectomy. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that the any current disability that caused a miscarriage has been aggravated (increased in severity beyond the natural progress of the disorder) by uterine fibroids or current residuals of a hysterectomy. A complete rationale for all opinions expressed should be clearly provided. 4. Obtain an opinion from an appropriate clinician to determine the nature and etiology of the anemia. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that the anemia is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region. The examiner should also opine whether it is at least as likely as not (50 percent probability or greater) that the anemia was caused by the uterine fibroids or current residuals of a hysterectomy. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that the anemia has been aggravated (increased in severity beyond the natural progress of the disorder) by uterine fibroids or current residuals of a hysterectomy. The examiner must consider the Veteran’s statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. A complete rationale for all opinions expressed should be clearly provided. 5. Obtain an opinion from an appropriate clinician to determine the nature and etiology of the fibrocystic breast disease. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that fibrocystic breast disease is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of lumpy breasts during service. The examiner must accept the Veteran’s reports of in-service breast symptomatology as credible. A complete rationale for all opinions expressed should be clearly provided. 6. Obtain an opinion from an appropriate clinician to determine the nature and etiology of a gastrointestinal disability. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a diagnosis for irritable bowel syndrome. For any gastrointestinal symptomatology that is not attributable to any current diagnosis for irritable bowel syndrome, the examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that any current gastrointestinal disability is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of irregular bowels during service. A complete rationale for all opinions expressed should be clearly provided. 7. Obtain an opinion from an appropriate clinician to determine the etiology of the disability manifested by body and muscle aches, and fatigue should be obtained. The need for a new VA examination is left to the discretion of the VA examiner. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. (a.) Identify any current body and muscle aches, and fatigue and/or fibromyalgia disability and fully describe the extent and severity of those symptoms. (b.) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such body and muscle aches, and fatigue or fibromyalgia disability arose during service or are otherwise related to any incident of service, to include serving in the Persian Gulf region. (c.) If the examiner finds no clinical diagnosis of any body and muscle aches, and fatigue or fibromyalgia disability that was incurred in, caused by, or otherwise related to the Veteran’s active military service, the examiner should provide an opinion as to whether the Veteran exhibits objective indications of an unexplained, chronic multisymptom illness due to an undiagnosed illness as defined under 38 C.F.R. § 3.317. For purposes of 38 C.F.R. § 3. 317 “objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. All opinions expressed by the examiner must be accompanied by a complete rationale. 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a skin disability. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on whether it is at least as likely as not (50 percent probability or greater) that any current skin disability is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of rashes during. The examiner must accept the Veteran’s reports of rashes as credible. A complete rationale for all opinions expressed should be clearly provided. 9. Obtain an opinion from an appropriate clinician to determine the nature and etiology of a headache disorder. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that any current headache disorder is related to an in-service injury, event, or disease, including reports of headaches during service. The examiner must accept the Veteran’s reports of headaches as credible. A complete rationale for all opinions expressed should be clearly provided. 10. Obtain an opinion from an appropriate clinician to determine the nature and etiology of any allergic rhinitis with nasal congestion disorder. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine on to whether it is at least as likely as not (50 percent probability or greater) that any current allergic rhinitis with nasal congestion disorder is related to an in-service injury, event, or disease, to include serving in the Persian Gulf region and reports of nasal congestion during service. The examiner must accept the Veteran’s reports of nasal congestion as credible. A complete rationale for all opinions expressed should be clearly provided. 11. Obtain an opinion from the February 2018 VA eye examiner for addendum opinions. If the February 2018 examiner is unavailable, obtain an opinion from an appropriate clinician. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The need for a new VA examination is left to the discretion of the VA examiner. Following a review of the record, the examiner must provide the following: (a.) Is it at least as likely as not (50/50 probability or greater) that the Veteran’s blepharitis (as documented in August 2011) began during or is otherwise related to service? (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran’s blepharitis (as documented in August 2011) is due to or aggravated by her service-connected dry eye syndrome? (c.) Is it at least as likely as not (50/50 probability or greater) that the Veteran’s conjunctivitis (as documented in August 2011) began during or is otherwise related to service? (d.) Is it at least as likely as not (50/50 probability or greater) that the Veteran’s conjunctivitis is due to or aggravated by her service-connected dry eye syndrome? 12. Issue a Supplemental Statement of the Case that addresses the increased rating claims for frostbite residuals in the hands and feet. After the Veteran and his attorney have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Kass, 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.