Citation Nr: 21061722 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 15-45 823 DATE: October 5, 2021 ORDER 1. Entitlement to an effective date prior to July 3, 2007, for the grant of service connection for left wrist degenerative osteoarthritis, is denied. 2. The appeal seeking entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is dismissed. 3. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. 4. Entitlement to a rating in excess of 10 percent for hypertension is denied. 5. A 20 percent rating is granted for the Veteran's right foot disability from June 24, 2015 to January 27, 2021, subject to the regulations governing payment of monetary awards; ratings for the disability in excess of 10 percent prior to June 24, 2015, and in excess of 10 percent from January 27, 2021, are denied. REMANDED 6. Entitlement to service connection for diabetes is remanded. FINDINGS OF FACT 1. A final October 2005 rating decision denied service connection for a left wrist disability; clear and unmistakable error (CUE) in that decision has not been alleged (and is not evident). 2. After the October 2005 rating decision, the first communication from the Veteran to VA seeking service connection for a left wrist disability was received on July 3, 2007. 3. An interim (October 2020) Decision Review Officer (DRO) decision granted service connection for posttraumatic stress disorder (PTSD), rated 100 percent, effective July 1, 2008, and awarded special monthly compensation (SMC) at the housebound rate effective July 1, 2008; the matter of entitlement to a TDIU from July 1, 2008 is rendered moot by the assignment of a 100 percent schedular rating and grant of SMC by the October 2020 rating decision. 4. The Veteran's left wrist disability is not shown to at any time under consideration have been manifested by symptoms/impairment consistent with (equivalent to) favorable or unfavorable ankylosis. 5. The Veteran's hypertension is not shown to have been manifested by diastolic pressures predominantly 110 or more or systolic pressures predominantly 200 or more. 6. Prior to June 24, 2015, the Veteran's right foot disability was manifested by symptoms and impairment reflecting no more than moderate foot injury; a moderately severe foot injury was not shown. 7. From June 24, 2015, to January 27, 2021, the right foot disability is reasonably shown to have been manifested by symptoms reflecting moderately severe foot injury; symptomatology reflecting a severe foot injury is not shown. 8. From January 27, 2021, the Veteran's right foot disability has been manifested by symptoms reflecting no more than moderate foot injury; symptoms and impairment reflecting or approximating a moderately severe foot injury are not shown. CONCLUSIONS OF LAW 1. An effective date earlier than July 3, 2007, for the grant of service connection for a left wrist disability is not warranted. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 2. The Veteran's appeal seeking a TDIU rating has been rendered moot by the October 2020 DRO decision grant of service connection for PTSD, rated 100 percent, effective July 1, 2008, and grant of SMC based on housebound status effective July 1, 2008; the Board has no further jurisdiction to consider an appeal in the matter. 38 U.S.C. §§ 7104, 7105. 3. A rating in excess of 10 percent for a left wrist disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (Codes) 5003, 5010, 5214, 5215. 4. A rating in excess of 10 percent for hypertension is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Code 7101. 5. A 20 percent (but no higher) rating is warranted for the Veteran's right foot disability from June 24, 2015 to January 27, 2021; ratings for the disability in excess of 10 percent prior to June 24, 2015, and from January 27, 2021, are denied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.71a, Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served in the Army Reserve from May 1975 to April 1981, on active duty in the Army from April 1981 to June 1989, in the Army National Guard from October 1993 to November 1996 and again in the Army Reserve until December 2004, with verified active duty in the Army from June 2003 to September 2004. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions that granted service connection for degenerative osteoarthritis of the left wrist, rated 10 percent, effective July 3, 2007 ( May 2011 ), denied entitlement to a TDIU rating ( February 2015 ), and denied service connection for diabetes and continued 10 percent ratings, each, for a left wrist disorder, hypertension, and right foot ganglion cyst removal ( July 2015 ). A December 2015 Board remand noted that the Veteran had expressed disagreement with the above rating decisions and directed that a Statement of the Case (SOC) be issued. In March 2017 separate SOCs were issued for the issues above, and thereafter the Veteran perfected an appeal in the matters. In April 2019, a videoconference hearing was held before the undersigned; a transcript is in the record. In September 2020, the case was remanded for further development. As noted above, an interim (October 2020) DRO decision granted service connection for PTSD rated 100 percent, and SMC at the housebound rate, from July 1, 2008. 1. Entitlement to an effective date prior to July 3, 2007, for the grant of service connection for left wrist degenerative osteoarthritis, is denied. Except as otherwise provided, the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. However, the service connection for a left wrist disability was granted based on a reopened claim, and the effective date of an award of compensation based on a reopened claim (after a final disallowance) is the date of new claim or the date entitlement arose, whichever is later [emphasis added]. 38 C.F.R. § 3.400(q)(2), (r). If there is a prior final VA denial of the benefit sought, the effective date cannot be earlier than a subsequent claim to reopen. See Leonard v. Principi, 17 Vet. App. 447 (2004); Sears v. Principi, 16 Vet. App. 244 (2002), aff'd 349 F.3d 1326 (Fed. Cir. 2003). "Nothing in the statute indicates that an effective date can be set based upon an application that resulted in a final disallowance of the claim." Wright v. Gober, 10 Vet. App. 343, 347 (1997). For the Veteran to be awarded an effective date based on an earlier claim, he or she has to show clear and unmistakable error (CUE) in the prior denial of the claim. Flash, 8 Vet. App. 332, 340 (1995); see also Rudd v. Nicholson, 20 Vet. App. 296, 299 (2006). The Veteran filed an original claim of service connection for a left wrist disability on December 21, 1990. A May 8, 1991 rating decision denied service connection claim, and the Veteran was notified of this decision on May 14, 1991. She did not file a timely notice of disagreement (NOD), and the May 1991 rating decision became final. CUE in that rating decision has not been alleged (and is not evident). The Veteran submitted a claim to reopen the claim of service connection for a left wrist disability on August 4, 2000. A May 14, 2002 rating decision denied the claim, and she was so notified on May 14, 2002. She did not file a timely NOD with the denial, and the May 2002 rating decision became final. CUE in that rating decision has not been alleged (and is not evident). The Veteran filed a claim to reopen the claim of service connection for a left wrist disability on December 17, 2004. An October 25, 2005 rating decision denied the claim, and the Veteran was so notified on November 7, 2005. She did not file a timely NOD with the denial, and the October 2005 rating decision became final. CUE in that rating decision has not been alleged (and is not evident). On July 3, 2007, VA received the instant claim seeking service connection for a left wrist disability. An August 2010 Board decision granted service connection for a left wrist disability, and a May 2011 rating decision implemented the Board's decision, assigning an effective date of July 3, 2007. In a July 12, 2011 statement, the Veteran asserted that the effective date should have been June 30, 2004 instead of July 3, 2007. At the April 2019 videoconference hearing, the Veteran continued to assert that the effective date should be from some time in 2004. As the October 2005 rating decision was the (latest) prior final denial of service connection for a left wrist disability under governing law and regulations (38 U.S.C. § 5110; 38 C.F.R. § 3.400 (q)(2)), and interpretive caselaw (cited above), an award of compensation (service-connection) for a left wrist disability may not be made effective prior to the filing of a claim to reopen (a new claim seeking service connection for a left wrist disability). There is no communication from the Veteran in the record seeking to reopen the claim of service connection for a left wrist disability received between November 2006 (when the October 2005 rating decision became final) and July 3, 2007. It has not been alleged that such a claim (informal under 38 C.F.R. § 3.155 (a) or formal under 38 C.F.R. § 3.157) was filed during that intervening period. There is no legal basis for an effective date for the award of service connection for a left wrist disability prior to the July 3, 2007 [receipt of claim to reopen] date assigned. The appeal seeking an earlier effective date for the award of service connection for a left wrist disability must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 2. Entitlement to a TDIU rating is dismissed. The Board has jurisdiction in any matter which, under 38 U.S.C. § 511(a), is subject to review on appeal to the Secretary. 38 U.S.C. § 7104(a). The Board may dismiss any appeal which fails to allege error of fact or law in the determination being appealed. 38 U.S.C. § 7105. As to the claim for a TDIU rating, as noted above, an interim (October 2020) rating decision granted service connection for PTSD at 100 percent, effective July 1, 2008. In her September 2014 VA Form 21-8940 (claim for TDIU), the Veteran reported she last worked full-time in September 2008. Accordingly, based on her own report, an effective date prior to July 1, 2008 would not be warranted. However, VA's duty to maximize benefits requires it to assess all of a claimant's service-connected disabilities to determine whether any combination of the disabilities establishes eligibility for SMC under 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2010); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In Bradley, the CAVC held that 38 U.S.C. § 1114(s) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a "total" rating. When a Veteran is awarded TDIU based on a single disability (as here) and receives schedular disability ratings for other conditions, SMC based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, that is, as a basis for TDIU and as a separate disability rated 60 percent or more disabling. As noted above, an October 2020 DRO decision also granted SMC at the housebound rate from July 1, 2008. Therefore, there is no question of fact or law in the matter remaining for the Board to consider; accordingly, the appeal seeking a TDIU rating must be dismissed as moot. 38 U.S.C. § 7105. INCREASED RATING Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Pertinent general policy considerations include: interpreting examination reports in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding degree of disability in favor of the claimant, 38 C.F.R. § 4.3; and, evaluating functional impairment based on lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is to be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. An increased rating may be assigned for up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred during that period. 38 C.F.R. §§ 3.157, 3.400(o)(2). Consequently, the period for consideration (for higher ratings for hypertension, right foot, and left wrist disabilities is from March 2, 2014 (one year prior to the March 2, 2015 date of claim) to the present. 1. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. As the Veteran is right-handed, the criteria for consideration in rating his left wrist disability are those pertaining to the minor extremity. Code 5215 provides for a (maximum) 10 percent rating if palmer flexion is limited in line with the forearm or if dorsiflexion is less than 15 degrees. A higher rating is available under Code 5214 (for ankylosis of the wrist). Under Code 5214, a 20 percent rating is warranted for favorable (in degrees to 30 degrees dorsiflexion) ankylosis of the minor wrist. Higher ratings may be assigned for ankylosis in other than favorable position. 38 C.F.R.§4.71, Plate I. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Under 38 C.F.R.§4.40, consideration must be given to functional loss due to pain and weakness causing additional disability beyond that reflected by range of motion measurements. Under 38 C.F.R. § 4.45, consideration must be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. Painful, unstable, or misaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R.§4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran's left wrist disability has been assigned a 10 percent rating, throughout, based on painful motion of the wrist. 38 C.F.R. § 4.59. On June 2015 VA wrist examination, left wrist degenerative osteoarthritis was diagnosed. It was noted that the Veteran was right-hand dominant. She reported pain with weight-bearing and range of motion, that she wore a left wrist splint at all times, and that she took Hydrocodone for pain. She related that tasks involving use of her left hand or wrist, such as grabbing objects or opening jars, were difficult for her due to wrist pain and that she experienced flare-ups when washing dishes that manifested as pain when she attempted to move her hands and that her left wrist weakened when she tried to hold a plate for a prolonged period or with repetitive use of the left wrist. Left wrist range of motion (ROM) testing showed palmar flexion to 30 degrees, dorsiflexion to 30 degrees, ulnar deviation to 30 degrees, and radial deviation to 10 degrees. Pain was noted on examination that did not result in functional loss. The pain was noted on all ranges of motion, but no pain was noted with weight-bearing. There was no localized tenderness, no crepitus, and no loss of function or ROM after repetitive use. Left wrist flexion and extension strength was 4/5, and there was no muscle atrophy. There was no ankylosis; the Veteran reported regular use of a left wrist brace. X-rays showed that a stable left hand with no acute bony abnormality or significant degenerative change. The examiner opined that the Veteran would have difficulty with tasks involving use of her left hand or wrist due to her left wrist disability. A June 2017 VA treatment record notes that the Veteran reported constant use of a left wrist brace. A March 2019 VA treatment record notes that the Veteran reported left wrist pain and that she wore a left wrist immobilizer. At the April 2019 videoconference hearing, the Veteran testified that she experienced left wrist limitation of motion with pain, took Hydrocodone, experienced left-hand weakness, and an inability to lift objects, and experienced left-hand numbness and tingling. On January 2021 VA wrist examination, it was noted that the Veteran was right-handed. Left wrist degenerative arthritis was diagnosed. It was noted that the Veteran had received physical therapy multiple times and had been managed with pain medication and a left wrist brace for many years. She reported shooting pain from her wrist to her elbow, numbness and tingling of the left hand, and weak left-hand grip. The examiner indicated that the Veteran's reports suggested carpal tunnel syndrome. The Veteran did not report flare-ups but did report functional loss because her left wrist has been compromised to some degree for 30 years. Left wrist ROM testing showed dorsiflexion to 25 degrees, palmar flexion to 25 degrees, ulnar deviation to 25 degrees, with pain on all ranges of motion. Passive ROM testing showed dorsiflexion to 20 degrees, palmar flexion to 30 degrees, ulnar deviation to 20 degrees, and radial deviation to 15 degrees. The examiner indicated that pain noted on active motion did not result in functional loss, but there was marked decrease in ROM due to pain and lack of use because the Veteran kept her left wrist in a brace at all times, except bedtime. No crepitus was shown, and there was modest pain on palpation of the wrist. There was no muscle atrophy and no left wrist ankylosis. Previous X-rays showed minimal cystic changes at distal scaphoid bone and the 1st carpo-metacarpal joint. The Veteran declined repetitive use testing, indicating that her left wrist was too painful, and she preferred "not to push the limits." The examiner noted that the Veteran's reports indicated pain caused functional loss with repeated use over time, but she was not examined upon repeated use over time because she her wrist was in a brace and does not use her left hand and/or wrist much, if at all. Additional factors affecting the disability included difficulty gripping objects and cold weather. The examiner opined that it would currently be impossible for her to engage in computer work. In an April 2021 addendum, (regarding repetitive use) the left wrist examiner noted that the Veteran did not use her left wrist, essentially keeping it in a brace at all times, so there was no time when the left wrist would be exposed to repeated use. The examiner speculated that ROM after repetitive use would be somewhat less than at baseline. On review of the record, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's left wrist disability at any time under consideration. A 10 percent rating under Code 5215 is warranted if palmer flexion is limited in line with the forearm or if dorsiflexion is less than 15 degrees. Under Code 5214, a 20 percent rating is warranted for favorable (in up to 30 degrees dorsiflexion) ankylosis of the minor wrist. No examination during the evaluation period found limitation of such severity; the greatest limitation of left wrist motion found on any examination was on January 2021 VA examination when range of motion testing found left wrist palmer flexion from 0 to 30 degrees [normal 80] and dorsiflexion from 0 to 20 degrees [normal 70]. Pain was noted on all motion and resulted in some functional loss. In other words, the greatest degree of limitation of motion shown, even considering factors of pain, falls squarely within the parameters of the criteria for the 10 percent rating (for painful motion under 38 C.F.R.§4.59) currently assigned. The Board notes that on January 2021 examination, the Veteran declined to be tested for repetitive use of the left wrist, and in an April 2021 addendum, the examiner opined that ROM after repetitive use would be somewhat less than at baseline. The Board has considered whether (based on that opinion) a separate 10 percent rating under Code 5215 for left wrist limitation of motion is warranted. and finds it is not. The record shows that the Veteran has been assigned a 10 percent rating for painful motion of the wrist under 38 C.F.R. § 4.59 and codes 5003 and 5010. As Codes 5215, 5003, 5010, all pertain to limited range of wrist motion and the Veteran is already being compensated for painful limitation of motion under Codes 5003 and 5010, the Board finds that a separate rating under Code 5215 would violate the prohibition on pyramiding. 38 C.F.R. § 4.14. No examination during the evaluation period found ankylosis (so as to warrant a rating under Code 5214). The preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's left wrist disability. Accordingly, the appeal in the matter must be denied. 2. Entitlement to a rating in excess of 10 percent for hypertension is denied. Hypertensive vascular disease (hypertension and isolated systolic hypertension) warrants a 60 percent rating when diastolic pressure is predominantly 130 or more. A 40 percent rating is warranted when diastolic pressure is predominantly 120 or more. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. A 10 percent rating is warranted when diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; as a minimum rating for an individual with a history of diastolic pressure predominantly 100 or more who requires continues medication. 38 C.F.R. § 4.104, Code 7101. An April 2014 VA treatment record notes blood pressure readings of 124/74, 118/71, and 113/72. Another April 2014 VA treatment record notes a blood pressure reading of 145/80. A January 2015 VA treatment record notes that the Veteran's blood pressure was 111/65. On June 2015 VA hypertension examination, it was noted that the Veteran's blood pressure medication was recently changed to Lisinopril since she is a newly diagnosed diabetic. The Veteran reported continuous use of medication and that her blood pressure was well controlled. Her current blood pressure readings were 142/86, 132/80, 140/80. The examiner noted that there was no history of diastolic blood pressure to predominantly 100 or more and opined that the Veteran's hypertension had no functional impact. An April 2016 VA treatment record notes that the Veteran's blood pressure was 139/104. A June 2017 VA treatment record notes that the Veteran's blood pressure was 136/87. A September 2018 VA treatment record notes that the Veteran's blood pressure was 171/99. A November 2018 VA treatment record notes that a review of the Veteran's October to November 2018 blood pressure readings indicated that the highest systolic reading was 168, the highest diastolic reading was 108, and the average reading was 149/93. A March 2020 VA treatment record notes that the Veteran's blood pressure was 145/91. On January 2021 hypertension examination, the examiner noted that the Veteran was prescribed Lisinopril (20 or 40 mg to be taken daily) and that she did not have a history of diastolic blood pressure to predominantly 100 or more. Her current blood pressure readings were 134/82, 138/90, 140/80. The examiner noted that the Veteran's hypertension had been controlled well for years with moderate doses of two anti-hypertensives. Throughout the period on appeal, the Veteran's blood pressure readings have fluctuated even with the use of medication as prescribed. The Board notes the criteria for rating hypertension specifically take into account the ameliorative effects of medication. Hence, the ameliorative effects of medications are not discounted, but are taken into consideration. McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016); See Jones v. Shinseki, 26 Vet. App. 56 (2012). There is no evidence in the record that at any time under consideration the Veteran's hypertension was manifested by a diastolic pressure of 110 or more, or a systolic pressure of 200 or more, much less diastolic pressures predominantly 110 or more, or systolic pressures predominantly 200 or more. In the absence of such manifestations, a rating in excess of 10 percent for hypertension is not warranted. 3. A 20 percent rating is granted for the Veteran's right foot disability from June 24, 2015 to January 27, 2021; ratings for the disability in excess of 10 percent prior to June 24, 2015, and in excess of 10 percent from January 27, 2021, are denied. The Veteran's right foot disability has been rated 10 percent under Code 5284 for "other" foot injuries. Under Code 5284, a 10 percent rating is warranted for moderate injury, a 20 percent rating is warranted for moderately severe injury, and a 30 percent rating is warranted for severe foot injury. A 40 percent rating is warranted with actual loss of use of the foot. The terms "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule or in the other regulations. Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. A March 2015 VA treatment record notes that the Veteran's right foot was normal in appearance; there were no open lesions, no bony deformity, no history of foot ulcer, and normal pedal pulse; reduced sensation was found on monofilament test. On June 2015 VA foot examination, right foot degenerative arthritis, and status post right foot ganglion cyst removal were diagnosed. The Veteran reported numbness and tingling in the right foot first and second toes, and pain and difficulty with wearing enclosed shoes. She related that she currently had throbbing right foot pain of 7/10, took Gabapentin and Lortab, and experienced pain upon prolonged standing and walking. She reported flare-ups when she wore shoes that covered her toes, and that during flare-ups she had difficulty walking or standing for a prolonged period. The examiner indicated that the right foot disability was mild in severity, did not chronically compromise weight bearing, and did not require arch supports or custom orthotics. On physical examination, right foot pain was noted that contributed to functional loss, and contributing factors of disability included pain on movement, weight bearing, and non-weight-bearing, all on the right. Regarding flare-ups or when the right foot is used repeatedly over time, the examiner noted that pain was worse with flexion and extension and aggravated with climbing stairs. A right foot 3 cm by 2 cm scar was not painful or unstable, and there was no skin atrophy. Right foot X-rays showed mild degenerative changes, no acute fracture or dislocation, and mild pes planus deformity. The examiner opined that the Veteran could engage in sedentary work, and that the right foot pain would make employment that required physical work such as prolonged standing or walking difficult. A March 2019 VA treatment record notes that the Veteran had a right foot ganglion cyst removed in 2006; on clinical examination, no gross pathology was noted other than a scar. At the April 2019 Board videoconference hearing, the Veteran testified that she experienced right foot numbness and tingling and that a scar was still visible. She related that she took Hydrocodone and Gabapentin. An August 2019 VA treatment record notes that a right foot assessment showed normal pedal pulses, and sensory examination was normal. An August 2020 VA treatment record notes that the Veteran's right foot showed normal sensation to monofilament. On January 2021 VA foot examination, removal of ganglion cyst of the dorsal aspect of the right foot, and mild degenerative joint disease (DJD) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints right foot, were diagnosed. The examiner noted that May 2012 and June 2015 X-rays showed minimal osteoarthritis of the right foot PIP and DIP joints. The Veteran reported numbness and tingling of her right foot first and second digits and mild right foot pain. The examiner suggested that since the Veteran has diabetes, the tingling and numbness could be due to diabetic peripheral neuropathy. On right foot examination, there was no evidence of pain on active or passive motion, or in weight-bearing or non-weight-bearing. The Veteran did not report flare-ups, and the examiner indicated that the Veteran's statements did not suggest right foot pain, weakness, fatigability, or incoordination, which significantly limited functional ability during flare-ups or after repeated use over time. The examiner opined that the right foot disability had no functional impact. Regarding whether a rating in excess of 10 percent for the right foot disability is warranted prior to June 24, 2015, the symptoms shown to that date (of an examination) most closely approximated a moderate (and not moderately severe) foot disability. Although records of right foot treatment during the period on appeal prior to June 24, 2015 are sparse, a March 2015 VA treatment record notes that the Veteran's right foot was normal in appearance, with no open lesions, no bony deformity, no history of foot ulcer, and normal pedal pulses. Accordingly, a rating in excess of 10 percent prior to June 24, 2015 is not warranted. The Board finds that from June 24, 2015, (the date of a June 2015 VA foot examination), to January 27, 2021 (the date of a January 2021 VA foot examination), the Veteran's right foot disability has presented a right foot disability picture consistent with moderately severe foot injury warranting a 20 percent rating under Code 5284. On June 2015 VA examination, although the examiner indicated that the right foot pain was mild, the Veteran related that she currently had throbbing right foot pain of 7/10 and experienced pain upon prolonged standing and walking. She reported flare-ups when she wore shoes that covered her toes (which most likely would have been rather often) and that during flare-ups, she had difficulty walking and/or standing for an extended period of time. On physical examination, right foot pain was noted that contributed to functional loss, and contributing factors of disability included pain on movement, weight bearing, and non-weight-bearing, all on the right. Regarding flare-ups or when the right foot was used repeatedly over time, the examiner noted that pain was worse with flexion and extension and aggravated with climbing stairs. The Board has considered whether the evidence shows a disability picture consistent with a severe foot injury (warranting a 30 percent rating) from June 24, 2015, to January 27, 2021, but finds that it does not. VA treatment records during the period do not note complaints of severe pain or severe difficulty with ambulation, and on June 2015 VA examination, there was no evidence of a marked deformity; that evidence weighs against a finding of a severe foot disability. Regarding whether a rating in excess of 10 percent for the right foot disability is warranted from January 27, 2021 (the date of a January 2021 VA foot examination), the symptoms shown from that date (those reported on examination) most closely approximate a moderate (and not moderately severe) foot injury. On January 2021 VA examination, the Veteran reported numbness and tingling of her right foot first and second digits and mild right foot pain. On right foot examination, there was no evidence of right foot pain on active, passive, weight-bearing, and non-weight-bearing range of motion testing. She did not report flare- ups, and the examiner indicated that her statements did not suggest right foot pain, weakness, fatigability, or incoordination, that significantly limited functional ability during flare-ups or after repeated use over time. Significant improvement is shown in the Veteran's right foot disability over that found prior to January 27, 2021 is shown and, accordingly, a rating in excess of 10 percent from January 27, 2021 is not warranted. A May 2021 DRO decision granted a 0 percent rating for right foot scar, effective, March 2, 2015; the appellant has not disagreed with that rating, or alleged any scar manifestations that would be separately compensable. REASONS FOR REMAND 6. Entitlement to service connection for diabetes. At the April 2019 videoconference hearing, the Veteran raised an alternate theory of entitlement to service connection for diabetes (that it was due to medication taken for her service-connected disabilities was caused or aggravated by her service-connected disabilities). In December 2020 a VA opinion-provider indicated that Depakote, prescribed for mental illness, can cause elevated blood sugars, but this medication was discontinued in 2018 and the Veteran's most recent A1c in 2020 still was indicative of type 2 diabetes mellitus. Therefore, it was less likely than not that the Veteran's diabetes was caused by the medication taken for her mental health disorder. The opinion is inadequate for rating purposes because it did not discuss the impact (if any) that the Veteran's other service-connected disabilities (and medication taken for such disabilities) had on her diabetes. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, remand for an adequate medical advisory opinion is necessary. The matter is REMANDED for the following: 1. Arrange for the Veteran's record to be forwarded to an appropriate clinician (other than the December 2020 opinion-provider) for review and an advisory medical opinion regarding the likely etiology for her diabetes, and specifically, whether it is caused or aggravated by her service-connected disabilities and medication taken for those disabilities. The consulting clinician should provide opinions that respond to the following: (a) Is it at least as likely as not (a 50% or better probability) that the diabetes is related to the Veteran's active military service/was incurred therein? (b) If her diabetes is determined to not be directly related to her service, opine whether it is at least as likely as not (that the diabetes was caused or aggravated (the opinion must address aggravation) by a service-connected disability, and/or medication she took for her service-connected disabilities. The consulting provider must include rationale with all opinions. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.