Citation Nr: 21061893 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 18-42 328 DATE: October 5, 2021 ORDER Entitlement to service connection for tinnitus is granted. Restoration of the previous 20 percent rating for service-connected left foot painful scars is granted. Entitlement to a 70 percent disability rating, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to a disability rating greater than 10 percent for service-connected right hip degenerative joint disease (hereafter referred to as a "right hip disability") is denied. Entitlement to a disability rating greater than 10 percent for service-connected left hip degenerative joint disease (hereafter referred to as a "left hip disability") is denied. Entitlement to a temporary total rating for convalescence for service-connected status post-surgery arthritis of the left first metatarsal phalangeal joint (hereafter referred to as a "left foot disability") is denied. Entitlement to a 30 percent disability rating for service-connected left foot disability is granted. Entitlement to a disability rating greater than 20 percent for service-connected left foot painful scars is denied. REMAND Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a skin disability, to include of the bilateral upper extremities, chest, stomach, and abdomen, is remanded. Entitlement to service connection for residuals of bilateral gynecomastia is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The evidence of record supports finding that the Veteran's tinnitus occurred in, or is the result of, his period of active duty service. 2. VA failed to follow the applicable procedural due process for rating reduction proceedings. 3. The Veteran's service-connected PTSD more closely approximates occupational and social impairment in most areas. 4. The Veteran's service-connected right hip disability does not exhibit ankylosis, limitation of flexion to at least 30 degrees, abduction lost beyond 10 degrees, flail joint of the hip, any impairment of the femur, or shortening of a lower extremity. 5. The Veteran's service-connected left hip disability does not exhibit ankylosis, limitation of flexion to at least 30 degrees, abduction lost beyond 10 degrees, flail joint of the hip, any impairment of the femur, or shortening of a lower extremity. 6. Surgery on the Veteran's service-connected left foot disability did not necessitate at least one month of convalescence or result in severe postoperative residuals. 7. The Veteran's service-connected left foot disability manifests severe symptoms. 8. The Veteran is service-connected for no more than two painful scars on his left ankle. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for restoration of the Veteran's previous 20 percent rating for his service-connected painful scars of the left foot are met. 38 C.F.R. § 3.105(e), (i). 3. The criteria for entitlement to a 70 percent disability rating, but no higher, for service-connected PTSD are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Codes (DC) 9411. 4. The criteria for entitlement to a disability rating greater than 10 percent for service-connected right hip disability are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 52505255, 5275. 5. The criteria for entitlement to a disability rating greater than 10 percent for service-connected left hip disability are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 52505255, 5275. 6. The criteria for entitlement to a temporary total rating for convalescence for surgery on the Veteran's left foot are not met. 38 U.S.C. § 1156; 38 C.F.R. § 4.30. 7. The criteria for entitlement to a 30 percent disability rating for service-connected left foot disability are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5284. 8. The criteria for entitlement to a disability rating greater than 20 percent for service-connected painful scars of the left foot are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.118, DCs 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2002 to June 2005 and November 2005 to October 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2015, September 2017, November 2017, and June 2018 Rating Decisions by a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was conducted via video conference with RO in. A transcript of this hearing is contained within the electronic claims file. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). In rendering a decision on appeal, the Board must analyze the competency, credibility, and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Buchanan v. Nicholson, 451 F.3d 1331, 133537 (Fed. Cir. 2006). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding any point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 5356 (1990); 38 C.F.R. § 3.102. Service Connection For disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. § 1110. To establish service connection, there must exist medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); 38 C.F.R. § 3.303(a). The Veteran argues that, while serving in the Marine Corps, he was an Infantryman in Security Forces, frequently exposed to weapons and explosions. Based on this noise exposure, he asserts that he began experiencing tinnitus during service. E.g., May 14, 2021, Hearing Transcript (Tr.) at 7. Service treatment records (STRs) do not show complaints of, treatment for, or diagnosis of tinnitus. The Veteran's DD-214 confirms that he served as a Rifleman and in Security Forces. A June 2017 post-service VA audiological examination noted that the Veteran reported recurrent tinnitus, but the examiner could not offer an opinion without resorting to speculation because, at that time, the Veteran's bilateral hearing loss also could not be tested due to "inconsistent responses which were not in agreement with each other . . . ." An August 2018 VA audiological examination confirmed that the Veteran reported recurrent tinnitus. In opining that the Veteran's tinnitus was at least as likely as not related to service, the examiner stated the following: Veteran served in the US Marine Corps from 2001-2005 and the US Army from 2005-2012. He reported exposure to noise from artillery, explosions, machinery, and small arms fire with HPDs. High probability of hazardous noise exposure was conceded. Veteran denied civilian and recreational noise exposure. It is at least as likely as not that the type and amount of noise experienced during military service was sufficient to cause Veteran's tinnitus. The Board is satisfied that the elements for direct service connection have been established. The Veteran currently suffers from recurrent tinnitus; it recognizes that he was exposed to hazardous noise by virtue of his military occupations; and a medical professional has opined that it is as least as likely as not that military noise exposure caused tinnitus. Thus, all three elements for direct service connection are present. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). Because the evidence of record supports the Veteran's claim for entitlement to service connection for tinnitus, his appeal for this issue is granted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53; 38 C.F.R. §§ 3.102, 3.303(a). Rating Reduction With a rating reduction that results in a reduction in the overall amount of compensation paid, VA must comply with the notice procedures of 38 C.F.R. § 3.105(e). Kitchens v. Brown, 7 Vet. App. 320, 325 (1995). When VA makes a rating reduction without following the applicable regulations, the reduction is void ab initio. Greyzck v. West, 12 Vet. App. 288, 292 (1999). VA must issue a rating action proposing the reduction and set forth all material facts and reasons for the reduction. The Veteran must then be given sixty days to submit additional evidence and thirty days to request a predetermination hearing. A rating action then will be taken to effectuate the reduction. 38 C.F.R. § 3.105(e), (i). In a July 2015 Rating Decision, VA proposed, among other reductions, to reduce from 20 percent to noncompensable the rating for the Veteran's service-connected left foot painful scars. VA issued to him the requisite notice informing him that, if the reductions took effect, his combined rating would decrease from 80 to 70 percent. The notice also advised him of his rights to submit additional evidence and request a hearing. Less than one week later, the Veteran wrote to VA opposing the proposed reductions and requesting a personal hearing. See Aug. 4, 2015, VA Form 21-4138. He also referenced additional VAMC records that he alleges showed his conditions had worsenednot improved. See Aug. 31, 2015, VA Form 21-4138. VA took no further action on the matter. It was not until a June 2018 Rating Decision that the VA reduced from 20 to 10 percent the Veteran's left foot painful scar rating. At the time of that reduction, the Veteran's overall compensation level did not decrease, so VA was not required to comply with the notice provisions. See Kitchens, 7 Vet. App. at 325; 38 C.F.R. § 3.105(e), (i). Nevertheless, VA chose to initiate the reduction proceedings in 2015; and the permissibly and timely requested to be heard on the matter. That VA chose to wait three years to reduce the Veteran's rating is irrelevant. It does not change the fact that the reduction proceedings have remained open and pending until this day, as no intervening rating decision determined to leave intact the Veteran's 20 percent rating before it was reduced in 2018. The potential effects of this denial of due process are of concern. Indeed, had VA reduced in 2018 the Veteran's scar rating to noncompensableas it originally had planned back in 2015it again would have resulted in an overall compensation rating drop to 70 percent (as opposed to 80 percent), triggering the notice provisions for reductions. See 38 C.F.R. §§ 3.105(e), (i), 4.25. Thus, on its face, it appears that VA overlooked its heightened duties to the Veteran detailed in the regulations. Such action is void from the beginning, and the Veteran's 20 percent rating must be restored. See Greyzck, 12 Vet. App. at 292. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119, 126 (1999). While a veteran's entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). "The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007) (discussing 38 U.S.C. § 5110 and 38 C.F.R. § 3.400(o)). In determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Ibid. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. 1. Entitlement to a 70 percent disability rating, but no higher, for service-connected PTSD is granted. For psychiatric disabilities, a 100 percent disability rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals, which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant a particular rating, but are not meant to be exhaustive, and the Board need not find all, or even some, of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). If the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a specific rating, the appropriate, equivalent rating will be assigned. Id. at 443. The rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). VA is precluded from differentiating between the symptoms of the Veteran's service-connected PTSD and those of her other mental disorders in the absence of clinical evidence that clearly shows such a distinction. See Mittleider v. West, 11 Vet. Ap. 181, 182 (1998). Furthermore, because all psychiatric disorders, with the exception of eating disorders, are evaluated under the General Rating Formula for Mental Disorders, a single evaluation will be assigned that encompasses all of the Veteran's overlapping psychiatric symptoms, however diagnosed. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). In a July 2015 Rating Decision, the Veteran was awarded service connection for PTSD; he was assigned a 50 percent rating effective July 2, 2015. The instant increased rating claim was filed in January 2018. In an April 28, 2017, VA medical center (VAMC) entry, the Veteran reports receiving a massage and going out to eat with his family for his birthday; he indicated that is "all he could manage." His mood has improved with medication and was less snappy with his wife. He has nightmares once a week and experiences irritability, depression, withdrawal, hypervigilance, flashbacks, insomnia, anxiety, avoidance of triggers, and feelings of emotional detachment. There were periods of heavy drinking, but he no longer drinks or has suicidal ideations; however, he states he owes both of those things to his renewed religious faith and belongs actively to his church family. There were no psychiatric admissions or suicide attempts, but the Veteran held a loaded pistol a couple of years ago in contemplation of suicide. In a June 2017 VAMC entry, the Veteran noted improvement with sleeping, mood, anxiety, and irritability. He and his wife went on a couple's retreat and began seeing a therapist to improve communication. He routinely began working out at a gym, cognizant of his limits. Nightmares improved to about twice a week. An October 2017 note states that he is doing "fairly well." His mood is manageable, but he tends to stay at home and utilizes avoidance as a coping mechanism. He has nightmares once a week, which he believes is reasonable; there were no flashbacks or suicidal/homicidal ideation. A January 2018 statement form the Veteran's childhood friendR.J.indicates that the Veteran has few friends and frequently declines requests to socialize with R.J. and R.J.'s son. According to R.J., the Veteran used to enjoy gardening and hiking but no longer engages in these activities; instead, the Veteran watches television and sleeps. The Veteran about once a month will stay in his house for a few days at a time. In February 2018, it was noted that the Veteran was self-medicating because his medication was not delivered by the United States Postal Service. He endorsed anger, depression, irritability, intrusive memories, hypervigilance, nightmares, and isolation. He and his wife have not been getting along, and he described his life as though it "totally turned around in a bad way." He struggled with the death of a male relative who "practically raised" him. He admitted to drinking daily, although, he was willing to stop. There was no suicidal or homicidal ideation, but he did get aggressive at the pharmacy and had to be escorted out by the police a while back. In April 2018, the Veteran reported being slightly less irritable and dysphoric, but that his symptoms were more manageable. There was no homicidal or suicidal ideation. Cognition was grossly intact in terms of immediate, recent, and remote memory functioning. Judgment and insight control were adequate. A May 2018 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The report confirms the Veteran's diagnosis of PTSD and unspecified depressive disorder, and it was not possible to differentiate the symptoms between the two. The examiner noted that the Veteran remains married to his wife of sixteen years but with an "'unstable'" relationship. The two experience miscommunication due to the Veteran desiring some space and sometimes lack intimacy. The Veteran has three sons, but his physical disabilities limit his interactions with them, and he and his wife disagree over discipline. When asked about friends and social activities, the Veteran stated that he has no friends and never leaves the house except for appointments. As far as educational history, the report notes that he obtained in 2015 a bachelor's degree in business administration but that he has not worked since 2015. Noted symptoms were depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbance of motivation or mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. In the remarks section, the examiner captured the following from the Veteran: "I still have nightmares about 4 times a week. I have anxiety. I will start to hyperventilate and my pulse races when I try to go out in public. I pace the floors at night and check doors. I depend on my medication day to day. My health has gotten worse." He reports having problems with his medications not being sent out or being stolen from the mail. "I feel worthless. I can just be sitting there and become angry all of a sudden." He reported having occasional suicidal ideation but denied intent and has not attempted to harm himself since his last exam three years ago. "I can just be sitting there and watching tv and have a flashback. My wife has had to wake me up because I am screaming. She says I look angry when I wake up and she has to talk to me to bring me back around. During the day I feel like I am stuck in a funk, and it becomes very, very heavy and I can't seem to get out of it." Overall, the examiner indicated that the Veteran's PTSD causes occupational and social impairment with reduced reliability and productivity. A July 2018 entry states that there was a mistaken report of suicidality. The Veteran's mother purportedly notified a VA employee that the Veteran was suicidal. In attempting to reach the Veteran, the Veteran's wife responded that VA was mistaken, and that the Veteran was not suicidal and that she had been with him all day and that he merely expressed anger over the pain in his left foot and that his primary care provider recently had been switched. In an August 2018 visit, he expressed anger at the VA system but adamantly denied suicidal ideation. His provider discussed coping by communicating with loved ones so as to assuage their concerns, and how to cope with stressors of dealing with VBA and VHA. He ceased taking Doxepin because his surgeon told him it can cause or add to gynecomastia. Thus, he hardly sleeps more than a few hours per night. He has previously tolerated Trazodone and was willing to resume that medication. By November 2018, he continued to grieve the passing of his grandmother. He endorsed dysphoric mood, avoidance, sleeping too much on meds, and having cognitive slowing from Pregabalin. Entries from FebruaryJune of 2019 show that the Veteran continued to keep his distance from certain family members due to their reactions with his grandmother's passing, and he endorsed "feel[ing] better isolated." His symptoms waxed and waned depending on his medications but appeared to take a negative turn as his relationship with his wife began to deteriorate. A March 2020 VA examination report noted mental examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The report confirms the Veteran's diagnosis of PTSD and unspecified depressive disorder, and it was not possible to differentiate the symptoms between the two. The examiner noted that the Veteran and the Veteran's wife separated in February 2019, and that she tries to keep the children from seeing the Veteran. He sees his children Saturday evening through Sunday afternoon. He still had not engaged in any employment since separation from active service. Noted symptoms were depressed mood, anxiety, suspiciousness, flattened affect, disturbance of motivation and mood, and inability to maintain effective relationships. In the relevant mental health history section, the examiner stated the following: Veteran reported his symptoms have improved slightly but he continues to experience the following symptoms consistent with PTSD: nightmares nearly every night, flashbacks that occur 13 times weekly, anxiety, uncomfortable in crowds, recurrent and intrusive memories, psychological and physiological distress related to the event, anxiousness, anger and irritability, avoidance behavior, negative beliefs about self and the world, distorted cognitions that lead veteran to believe he was at fault, guilt and shame associated with the event, diminished interest in pleasurable activities, problems with concentration, exaggerated startle response, sleep disturbance, and feelings of detachment from others. Veteran also reported the following symptoms consistent with an unspecified depressive disorder: depressed mood daily, lack of motivation, difficulty with focus and concentration, and anxiety. Overall, the examiner indicated that the Veteran's PTSD causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation. Notes from September 2019 and January 2020 show that the Veteran's divorce proved to be rather acrimonious. This made the Veteran feel anxious, nervous, hypervigilant, and unsafe. Nightmares were regular and sleep was mediocre. The Veteran continues to keep to himself utilizing avoidance as a mitigating core arousal symptom. In January 2021, the Veteran submitted a private PTSD Disability Benefits Questionnaire (DBQ) completed in November 2020 by Dr. J.L. The report confirms the Veteran's diagnosis of PTSD and unspecified depressive disorder; it was possible to differentiate the symptoms between the two. Dr. J.L. noted that the PTSD produced avoidance, cognitive/mood distortion, intrusive memories, and autonomic arousal. The depression caused depressed mood, hopelessness, and loss interest. The Veteran still was separated from his wife and not engaged in employment. Noted symptoms were depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, flattened affect, difficulty understanding complex commands, impaired judgment, impaired abstract thinking, difficulty adapting to stressful circumstances, including work or a work-like setting, disturbance of motivation and mood, inability to maintain effective relationships, impaired impulse control, such as unprovoked irritability with periods of violence, and neglect of personal hygiene. Dr. J.L. also attached a seven-page report regarding his assessment of the Veteran, the bulk of which captures the information contained within the DBQ. Overall, Dr. J.L. believes that the Veteran's PTSD causes total occupational and social impairment. At his May 2021 hearing, the Veteran endorsed rarely talking to any family, insomnia, hypervigilance, nightmares, avoiding public places, and short-term memory loss. Tr. at 1618. The Board finds that a 70 percent rating, but no higher, is warranted for the Veteran's service-connected PTSD. As noted above, a 70 percent rating requires occupational and social impairment with deficiencies in most areas, and this adequately describes the Veteran. As it pertains to social impairment, the record thoroughly shows that the Veteran mostly keeps to himself, save for interaction with his wife children, and even the former began deteriorating. There also is evidence that the Veteran enjoys and actively participates with his religious "church family." The Board, however, recognizes that that information was from 2017. The record lacks any discussion of other friends or social engagements and habitually verifies the Veteran's preference to avoid others and be left alone. R.J., the Veteran's childhood friend noted the Veteran's persistent decline to engage in fishing and other activities, preferring to stay inside the house. The Veteran himself also stated that her rarely engages with his sons and prefers to stay in the house most of the time. Regarding occupational impairment, the Board likewise finds that the Veteran would experience impairment commensurate with a 70 percent rating. While the Veteran ultimately was granted disability benefits from the Social Security Administration (SSA) for his peripheral neuropathy, the administrative decision noted that the Veteran's depression as a "non-severe" impact on his ability to work. That decision, however, was rendered in October 2013 and could not have considered the current severity of the Veteran's psychiatric disability. As the various VA examinations show, the Veteran would have difficulty, or, in some instances, an inability, establishing effective relationships, including those in a work or work-like setting. This, of course, would cause occupational impairment for the Veteran. Thus, the Board is satisfied that the Veteran displays the necessary occupational and social impairment to qualify for a 70 percent rating. See 38 C.F.R. § 4.130, DC 9411. It is unpersuaded, however, that he is entitled to anything higher than a 70 percent rating. True enough, Dr. J.L. believes that the Veteran's PTSD produces total social and occupational impairment, but that opinion is not supported by the contemporaneous evidence of record. Recall that a total schedular rating for a psychiatric disability requires both total social and occupational impairment. While the Veteran may have diminished social interactions, he still sees his sons on some occasions, however brief. Furthermore, the evidence does not suggest that he would be incapable of employment solely due to his psychiatric symptoms. While the Board concedes that they would no doubt hinder his employability, it finds that he experiences greater impact to employability via his other service-connected conditions. Even if the Board were to find that the Veteran's psychiatric symptoms manifested total occupational impairment, because it likewise finds that total social impairment is not present, the Veteran still would not be entitled to a total rating. Thus, the Board finds that a 70 percent rating and no higher is appropriate. See ibid. 2. Entitlement to a disability rating greater than 10 percent for service-connected bilateral hip disabilities is denied. The Veteran seeks additional compensation for his service-connected bilateral hip disabilities. DC 5250 is assignable for ankylosis of the hip. A 90 percent disability rating is warranted for ankylosis unfavorable, extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated. A 70 percent disability rating is warranted for intermediate ankylosis. A 60 percent disability rating is proper where there is favorable ankylosis, in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. DC 5251 is applicable for limitation of extension of the thigh. To qualify for a 10 percent disability rating, extension of the hip and thigh must be limited to 5 degrees. DC 5252 is assignable for limitation of flexion of the thigh. To qualify for a 40 percent disability rating, flexion must be limited to 10 degrees or more. A 30 percent disability rating requires flexion limited to 20 degrees. A 20 percent disability rating requires limitation of flexion to 30 degrees. A 10 percent disability rating require limitation of flexion to 45 degrees. DC 5253 is assignable for impairment of the thigh. In order to qualify for a 20 percent disability rating, the Veteran must experience abduction lost beyond 10 degrees. In order to qualify for a 10 percent disability rating, the Veteran must have either limitation of adduction with an inability to cross legs, or limitation of rotation with an inability to toe-out more than 15 degrees with the affected leg. DC 5254 is assignable for flail joint of the hip and is awarded an 80 percent disability rating. DC 5255 is assignable for impairment of the femur. An 80 percent disability rating is assignable for fracture of the shaft or anatomical neck of the femur with nonunion and loose motion (spiral or oblique fracture). A 60 percent disability requires fracture of the shaft or anatomical neck of the femur with nonunion, without loose motion, and weight bearing preserved with the aid of brace; or, fracture of the surgical neck of the femur with false joint. A 30 percent disability rating requires malunion of the femur with marked knee or hip disability. A 20 percent disability rating requires malunion of the femur with moderate knee or hip disability. A 10 percent disability rating requires malunion of the femur with slight knee or hip disability. DC 5275 is assignable for shortening of the bones of the lower extremity. A difference of over 4 inches (10.2 cms) carries a 60 percent disability rating. A 50 percent disability rating requires a difference of 3.54 inches (8.9cms10.2cms). A 40 percent disability rating requires a difference of 33.5 inches (7.6cms8.9cms). A 30 percent disability rating requires a difference of 2.53 inches (6.4cms7.6cms). A 20 percent disability rating requires a difference of 22.5 inches (5.1cms6.4cms). A 10 percent disability rating requires a difference of 1.252 inches (3.2cms5.1cms). Normal hip flexion is 0125 degrees, and normal hip abduction is 045 degrees. 38 C.F.R. § 4.71a, Plate II. The Board notes that, during the pendency of this appeal, VA has amended the rating criteria for the musculoskeletal system contained in 38 C.F.R. § 4.71a. These changes take effect February 7, 2021, and cannot be applied prior to that date. Beginning that date, however, the Board will apply the rating criteria that is more favorable to the Veteran: either the old or the new criteria. 85 Fed. Reg. 76,453, 76,469 (Nov. 30, 2020). As it pertains to this appeal, malunion of the hip under DC 5255 has undergone changes. Any form of malunion is evaluated under DCs 5256, 5257, 5260, or 5261 for the knee, or 52505254 for the hip, which ever yields greater compensation for the Veteran. Id. at 76,463. When assessing the severity of musculoskeletal disabilities that are, at least partly, rated on the basis of limitation of motion, VA also must consider the extent that a veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when a veteran's symptoms are most prevalent ("flare-ups") due to the extent of his or her pain (and painful motion), weakness, premature or excess fatigability, and incoordination, assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 20407 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. A February 2013 Rating Decision granted the Veteran service connection for his bilateral hip disabilities; he was assigned a 10 percent evaluation for each, effective October 27, 2012. These awards were based on the documented arthritis in conjunction with painful motion. The Veteran filed the instant increased rating claim in December 2017. A June 2018 Rating Decision denied that request, and the Veteran timely appealed. See Aug. 7, 2018, NOD. VAMC entries from February and April 2017 showed that the Veteran had no hip pain with flexion or rotation, but a December 2017 note reveals chronic hip pain. Private treatment records from March 2018 shows that the Veteran has internal rotation of the thighs to 20 degrees and external rotation to 45 degrees; there is a positive impingement sign with flexion and internal rotation. Of record are January and May 2018 VA hip examinations, but, because they are not compliant with the requirements of Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017) (requiring VA examiners to opine on additional loss of ranges of motion for repeated use over time or after a flare-up and, if unable, to provide an adequate opinion explaining why not) they are inadequate, so the Board will not discuss them. January and May 2018 scans of the left and right hips, respectively, each revealed "no acute displaced osseous fracture," "significant joint space narrowing or marginal osteophyte formation." The right hip was described as "normal," while the left was described as having no "significant radiographic abnormality of the left hip to correlate with the provided clinical history of left hip pain." A July 2018 Gulf War examination noted that the Veteran had no pain on hip flexion or rotation. Private treatment records from January 2019 show that the Veteran experienced after a spinal cord simulator bilateral hip pain, more so in his left, that shoots down to his foot. A February 2020 VAMC note indicates that the Veteran has internal rotation hip pocket pain. A March 2020 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The Veteran did not report flare-ups, but he reported functional limitation as worsening pain with prolonged walking and standing, relieved by sitting. For both hips, initial ranges of motion were as follows: flexion: 0100 degrees, extension: 030 degrees, abduction: 035 degrees, adduction: 025 degrees, external rotation: 060 degrees, internal rotation: 040 degrees. Adduction for either hip was not so limited that the Veteran could not cross his legs, and there was pain on flexion, extension, and abduction. Objective evidence of localized tenderness or pain on palpation was described as mild hip pain due to degeneration. For both hips, the Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of range of motion. While the Veteran was not observed immediately after repeated use over time, the examiner opined that each hip would experience the following loss of range of motion: flexion: 090 degrees, extension: 020 degrees, abduction: 030 degrees, adduction: 025 degrees, external rotation: 060 degrees, internal rotation: 040 degrees. Muscle strength was normal, and there was no presence of atrophy. There was no ankylosis, impairment of the femur, flail hip joint, or leg length discrepancy. There were no assistive devices noted. Imaging studies were performed and confirmed minimal bilateral degenerative arthritis of the hips. There was no objective evidence of pain on non-weight bearing, and passive range of motion testing yielded the same results as active range of motion testing. The Veteran's bilateral hips require no prolonged walking or standing. At the hearing, the Veteran's Representative indicated that the Veteran had no other evidence to offer on these issues other than the fact that his hips cause him pain. Tr. at 23. The Board finds that the Veteran's current 10 percent disability rating adequately compensates him for his bilateral hip disabilities. The medical evidence of record and VA examination do not disclose any ankylosis, flail joint, impairment of the femur, or shortening of the lower extremity. With regards to limitations on range of motion, the Veteran does not experience limitation of flexion to at least 30 degrees or abduction lost beyond 10 degrees. The Veteran indeed is competent to report the pain he experiences in his bilateral hips, see Layno v. Brown, 6 Vet. App. 465, 469 (1994); however, recall that painful motion due to arthritic changes was the original basis for the Veteran's 10 percent award. Thus, the Board is satisfied that his painful motion has been taken into consideration with his current rating, and that no higher rating is warranted. See DeLuca, 8 Vet. App. at 20407; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 52505255, 5275. Thus, his appeal on these issues are denied. 3. Entitlement to a temporary total rating for convalescence for service-connected left foot disability is denied. The Veteran alleges he improperly was denied this benefit because VA "believed that [his] convalescence did not meet the minimum 30 day criteria"; he asserts that his period of convalescence was greater than the one-month requirement. Aug. 6, 2015, Notice of Disagreement (NOD). A total disability rating of 100 percent will be assigned without regard to other provision of the rating schedule when it is established by report at hospital discharge, regular discharge, or release to non-bed care, or outpatient release, that entitlement is warranted. 38 C.F.R. § 4.30. A temporary total rating for convalescence will be assigned from the date of hospital admission and continue for one, two, or three months from the first day of the month following hospital discharge when treatment of a service-connected disability results in (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body case, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30(a). The total rating will be followed by an open rating reflecting the appropriate schedular evaluation; where the evidence is inadequate to assign the schedular evaluation, a physical examination will be scheduled prior to the end of the total rating period. An extension of one, two, or three months beyond the initial three months may be granted and extensions of one or more months up to six months beyond the initial six months period may be made, upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.30(b). Convalescence is defined as the stage of recovery following an attack of disease, a surgical operation, or an injury. Felden v. West, 11 Vet. App. 427, 430 (1998) (citing Dorland's Illustrated Medical Dictionary (28th ed. 1994)). Recovery has been defined as "the act of regaining or returning toward a normal or healthy state." Ibid. (citing Webster's Medical Desk Dictionary (1986)). The purpose of a temporary total evaluation is to aid a claimant during the immediate post-surgical period when he or she may have incompletely healed wounds or may be wheelchair-bound, or when there may be similar circumstances indicative of transient incapacitation associated with recuperation from the immediate effects of an operation. 38 C.F.R. § 4.30. Notations in the medical record as to the claimant's incapacity to work after surgery must be taken into account in the evaluation. Ibid.; see also Felden, 11 Vet. App. at 430; Seals v. Brown, 8 Vet. App. 291, 29697 (1995). In a February 2013 Rating Decision, the Veteran was awarded service connection for his left foot disability; he was assigned a 20 percent evaluation effective October 27, 2012. In June 2015, the Veteran filed the instant claim specifically seeking "Para 30 claim for surgery on Service Connected Left Foot." He was denied that benefit via a July 2015 Rating Decision, and he timely appealed. The Veteran underwent in May 2015 a surgical procedure on his left foot for neuritis, nerve entrapment, and painful scar tissue. The disposition of the surgery was noted as the following: The patient will continue morphine for pain control. The patient was advised to keep dressings clean, dry and intact. Limited activity to the foot. Upon resting, elevate the limb. The patient was instructed to return to clinic for postoperative care in Mobile, Tuesday, June 2, 2015, at 11:15 a.m. The patient was also instructed if the dressing should become wet or dry, to call the hospital immediately and follow instructions. The patient was also instructed if any signs of uncontrolled fever, pain, nausea, or vomiting, to immediately go to the nearest ER and follow up with Podiatry. Postoperative notes limited the Veteran's activities to bed rest and bathroom for the first three days. He was placed in a surgical boot and instructed not to walk on his foot while using the boot; ambulation via crutches or a wheelchair were required. The Veteran also was instructed to keep his foot elevated and to ice it. He initially noted his postoperative pain as "tolerable" but rated it 9/10 the following day. VAMC follow-up visits in June 2015 show that the Veteran's pain was well controlled with medication and; by June 12, 2015, he was ambulating without the assistance of crutches. A July 2015 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The report noted the Veteran's most-recent surgery. He did not report flare-ups or functional loss but did note a needle-like sensation when he puts pressure on the foot. The frequency is constant (at least five times a day), lasting about one hour; however, cold-water compression alleviates the pain. Standing tenfifteen minutes can aggravate the pain. August 2015 VAMC entries show that the Veteran's sensitivity to his left foot had diminished but that he was having sharp pain with weight bearing, which felt like a stress fracture. Nevertheless, he was able to ambulate fully on the left foot and not just on the side. The examiner also noted normal scarring to medial left hallux, tender to palpate of the medial first metatarsal phalangeal joint and slightly to plantar aspect and over the scar. There was no pain with range of motion except for force dorsiflexion. Tenderness to palpitation of tibial sesamoid area was present, but there was no pain proximal to the incision. Residual edema was nonpitting. He explained to the Veteran that the skin is healed, but the scarring may take up to one year, if not more, to remodel itself. Sensitivity to the toes and foot will fade over the next six months because this was the fourth surgery, and residual postoperative edema is common and could be lifelong. At his hearing, the Veteran testified that it took him about "two months" to recover from his May 2015 surgery. Tr. at 14. He further testified that he was unable to leave his house and had to use crutches during those full two months to get around. Id. at 15. Recall above that there are three avenues under 38 C.F.R. § 4.30(a) by which one can qualify for a temporary total rating. The third avenueimmobilization by cast, without surgery, of one major joint or moreis inapplicable. That option, as it clearly states, is reserved for instances where there has been no surgery. Because the Veteran did undergo surgery, he does not qualify based on that subsection. That leaves two remaining avenues for the Veteran to succeed: subsection (a)(1) or (a)(2). For the reasons discussed below, the Board does not find that the evidence shows that he meets either. The record does not reflect that the Veteran sustained at least one month of convalescence pursuant to § 4.30(a)(1). Contrary to his assertions, see Tr. at 1415; Aug. 6, 2015, NOD, his doctor prescribed him to stay in bed and off his left foot for the first three days after surgery. In less than three weeks following surgery, he was ambulating without the use of crutches. These contemporaneous postoperative treatment notes contradict the Veteran's testimony that he was unable to leave the house and on crutches for two months. Indeed, relevant clinical records note he was off crutches in about three weeks. Thus, the Board does not find credible the Veteran's assertions on this matter, and it further finds that the Veteran did not undergo at least one month of convalescence after his surgery. See Felden, 11 Vet. App. at 430. The last avenue likewise is of little help to the Veteran. The Board recognizes that, where the applicable rating criteria contains terms that are undefined, the Board must define those terms as it applies them to the veteran at hand to satisfy its obligation to provide adequate reasons or bases. Johnson v. Wilkie, 30 Vet. App. 245, 25455 (2018); Spellers v. Wilkie, 30 Vet. App. 211, 21920 (2018). "Severe" postoperative residuals are not present here. 38 C.F.R. § 4.30(a)(2). As discussed above, the Veteran very soon after surgery was able to walk without crutches. At the July 2015 VA examination, he denied both flare-ups and functional limitation. Furthermore, by August 2015, he admitted that the sensitivity in his left foot had diminished, but that there was pain with weightbearing. There is no objective evidence that pain was so severe that as to prevent him from properly ambulating fully on his own. There was "normal" scarring and no pain on range of motion except dorsiflexion. The skin was healed, but the scar could take up to one year to heal fully. Thus, the Board does not find that this medical evidence reveals that the Veteran was suffering from "severe" postoperative residuals. While there were some residuals, such as generalized pain, it did not rise to the level of "severe" as evidence by the contemporaneous treatment notes. Thus, the Board finds that the Veteran does not qualify for a temporary total disability rating for his service-connected left foot disability following his May 2015 surgery. See 38 C.F.R. § 4.30(a). 4. Entitlement to a 30 percent disability rating for service-connected left foot disability is granted. The Veteran believes he is entitled to a rating greater than 20 percent. For any foot condition not articulated within the rating schedule, DC 5284 permits a severe, moderately severe, and moderate characterization, warranting a 30, 20, or 10 percent evaluation, respectively. Actual loss of use of the foot warrants 40 percent. In a February 2013 Rating Decision, the Veteran was awarded service connection for his left foot disability; he was assigned a 20 percent rating effective October 27, 2012. The Veteran filed the instant claim in December 2017. In a December 2016 letter, Dr. R.B. states that the Veteran has been under his care since December 2015 and has been diagnosed with left foot sesamoid, Freiberg's infraction of the second metatarsal, neuritis, a painful scar, and metatarsalgia. Private treatment records from January 2017 reveal that the Veteran complained of left leg pain due to a 2009 motor vehicle accident. Pain is sharp and achy and increases with walking, standing, and correlates to the weather. He reported being placed in a boot from another treating podiatrist. Private October 2017 records show similar complaints. On his September 2018 VA Form 9, the Veteran indicates his left foot disability causes persistent pain and that he has been prescribed a transcutaneous electrical nerve stimulation (TENS) unit. He endorses taking daily Morphine and Buprenorphine. In a November 2018 statement, he reiterated persistently seeing a podiatrist and that his left foot keeps him immobilized most days. He endorses injections in his feet for the pain. An August 2019 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The examiner noted the Veteran's left foot disability with "moderate" functional limitation. In the Medical History section of the report, the examiner notes left foot pain that is "daily and constant"; the Veteran uses Lidocaine patches 24/7; takes Morphine (15mg), Methocarbamol, and Lyrica (all twice a day); and receives cortisone shots once every six months at the first metatarsal joint. During the examination, the Veteran was using a Lidocaine patch, but he did not want the examiner to touch his foot due to "extreme pain" and "hypersensitivity." According to the Veteran, anytime anyone tries to examine and manipulates his he must go to the emergency room for treatment immediately afterwards. The report indicates that he ambulates on the "lateral side" of the left foot. The report notes the Veteran's two surgeries in 2010, as well as the ones in 2012 and 2014, and indicates that the residuals are "chronic left foot pain syndrome." The Veteran experiences less movement than normal, pain on movement and weight-bearing, and "daily and constant pain." A March 2020 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The report notes "moderate to severe pain across the [l]eft great toe with touch and weight bearing" and flare ups with "severe pain" requiring him to rest with weight bearing. Overall, this examiner rated the Veteran's condition as mild. The Veteran testified at the hearing that his left foot pain is a constant 10/10 and that it feels like he is walking on glass. Tr. at 1920. Other VAMC and private treatment records document the Veteran's pain he experiences, as well as the medication and various forms of pain management he uses. Reviewing the pertinent evidence of record, the Board finds that the Veteran's symptoms are severe. Just as the term "severe" is not defined for purposes of convalescence, it likewise is not defined in DC 5284 and requires the Board to explain its definition as applied to the Veteran at hand. See Johnson, 30 Vet. App. at 25455. The Veteran utilizes a variety of treatment methods for his pain: prescription drugs, creams, injections, a TENS unit, etc., all of which provide temporary relief. The Veteran has indicated that he is in constant pain, Tr. at 1920, and the two VA examiners note that the Veteran endorses and experiences "severe" pain, despite their overall characterization of the Veteran's disability as mild and moderate. The extensive medical history and treatment recounted by the August 2019 VA examiner clearly shows that the Veteran experiences "severe" symptoms for his left foot disability. Thus, a 30 percent disability rating is warranted. See 38 C.F.R. § 4.71a, DC 5284. Because this is the highest schedular rating under DC 5284, and because the evidence does not suggest that the Veteran has "actual loss of use" of his left foot, this is a full grant of benefits on appeal. 5. Entitlement to a disability rating greater than 20 percent for service-connected left foot painful scars is denied. The Veteran argues that he is entitled to a rating higher than 20 percent for his left foot painful scars. Because the appeal for this increased rating claim goes back to August 7, 2018, different versions of the rating criteria could be applicable, depending on what is more favorable to the Veteran. See Kuzma v. Principi, 341 F.3d 1327 (2003); VAOPGCPREC 7-2003; VAOPGCPREC 3-2000. The Board, however, may not apply any given rating criteria before its effective date. See 38 U.S.C. § 5110(g). Relevant to this appeal, there were two amendments: October 23, 2008, and August 13, 2018. Thus, the Board will discuss the criteria during all stages of the appeal and apply the appropriate, most-beneficial standards where applicable. Under the October 2008 criteria, DC 7804 is applicable to unstable or painful scars. Five or more scars warranted a 30 percent rating. Three or four scars warranted a 20 percent rating. One or two scars warranted a 10 percent rating. Note (1) defined an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if one or more are both unstable and painful to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) stated that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC when applicable. 73 Fed. Reg. 54,708, 54,71011 (Sept. 23, 2008). DC 7805other scars including linear scar and other effects of scarswere to be evaluated under DCs 78007804. Id. at 54,7111. Under the modern criteria, DCs 7804 and 7805 remain unchanged. A February 2013 Rating Decision awarded service connection for the left foot painful scars; the Veteran was assigned a 20 percent rating effective October 27, 2012. Beginning the date of service connection, the left foot painful scars were rated under DC 7805. As of January 23, 2018, they have been rated under 7804. As discussed above, the Veteran never formally filed for an increase for his left foot painful scars; instead, VA improperly reduced his rating to 10 percent, and he timely appealed the rating, which also included the propriety of the reduction. An August 2019 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. The report indicates that there are two scars on the Veteran's left foot. One measures 8 centimeters (cm) by 0.5cm, and the other measures 7cm by 0.2cm. the Veteran reported that both scars are painful, and both are tender to palpation; however, neither scar has underlying soft tissue damage. A March 2020 VA examination report noted physical examination of the Veteran and review of the claims file and recited the Veteran's complaints and medical history. This examination yielded slightly different measurements for the Veteran's scars: 7cm x 0.5 cm for both. Both still were tender to palpation, but neither were unstable nor contained underlying soft tissue damage. As noted above, a 30 percent rating requires five or more painful scars. The record clearly shows that the Veteran has only two. Based on a straightforward application of the rating criteria, he does not qualify for a rating greater than 20 percent. See 38 C.F.R. § 4.118, DC 7804, 7805. Thus, his appeal on this issue is denied. REASONS FOR REMAND If further evidence, clarification of the evidence, correction of a procedural defect, or any other action is essential for a proper appellate decision, a Veterans Law Judge (VLJ) shall remand the case to the agency of original jurisdiction (AOJ), specifying the action to be undertaken. 38 C.F.R. § 20.904(a). 6. Entitlement to service connection for bilateral hearing loss is remanded. In a claim for disability compensation, VA will make efforts to obtain the claimant's service medical records, if relevant to the claim; other relevant records pertaining to the claimant's active military, naval or air service that are held or maintained by a governmental entity; VA medical records or records of examination or treatment at non-VA facilities authorized by VA; and any other relevant records held by any Federal department or agency. The claimant must provide enough information to identify and locate the existing records including the custodian or agency holding the records; the approximate time frame covered by the records; and, in the case of medical treatment records, the condition for which treatment was provided. 38 C.F.R. § 3.159(c)(3). This provision "extends the VA's duty to assist to obtaining sufficiently identified VA medical records or records of examination or treatment at non-VA facilities authorized by VA, regardless of their relevance." Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). If, after continued efforts to obtain federal records, VA concludes that it reasonably is certain the records do not exist or further efforts to obtain them would be futile, then it will provide the claimant with oral or written notice of that fact. VA will make a record of any oral notice conveyed to the claimant. That notice must contain the identity of the records that VA could not obtain; an explanation of VA's efforts; a description of any further action VA will take regarding the claim, including, but not limited to, notice that VA will decide the claim based on the evidence of record unless the claimant submits the records VA was unable to obtain; and notice that the claimant is ultimately responsible for providing the evidence.38 C.F.R. § 3.159(e). At the hearing, the Veteran testified that he received at the Pensacola Navy Hospital treatment for his bilateral hearing loss and that his most recent audiological examination was in 2018 or 2019. Tr. at 8. The Representative informed the undersigned VLJ that they did not "submit that" because "you could not read it very well." Ibid. The Board sincerely appreciates the Representative's candor in this matter, but that does not obviate VA's duty to obtain records held by other federal agencies. This evidence especially could prove useful to the Veteran's claim since his last VA audiological examination was in August 2018, which does not show a current diagnosis of bilateral hearing loss for VA compensation purposes. See 38 C.F.R. § 3.385. Thus, remand is required for VA to make attempts to obtain these records. See Sullivan, 815 F.3d at 793; 38 C.F.R. §§ 3.159(c)(3), 20.904(a). 7. Entitlement to service connection for a skin disability, to include of the bilateral upper extremities, chest, stomach, and abdomen, is remanded. The Veteran contends that he has experienced rashes on his body during active duty shortly after returning from deployment in Iraq; he notes being prescribed various medications and topical ointments and that the condition has continued to this day. Tr. at 3, 7. A July 2018 Gulf War VA examination contains a succinct recount of the medical history of the Veteran's complicated skin disability. A May 2009 STR note reveals that the Veteran suffered a rash on his neck and chest; the diagnosis was dermatitis due to hot weather. A July 2011 entry indicates itchy lesions for the past month and a diagnosis of dermatophytosis (tinea corporis). Shortly before separation (August 2012), the Veteran was prescribed Cortisone and Ketoconazole cream for his dermatitis; small lesions were noted on the upper extremities. In July 2014, the Veteran presented to a VAMC where he had irregular hypopigmented areas just proximal to the antecubital fossa on each arm. The diagnosis was tinea versicolor. An October 2014 entry noted similar hypopigmentation on the upper chest. This was confirmed in January 2016. A May 2018 dermatology note stated the following: Patient is here for follow-up of rash on the chest neck arms and buttock reg. He was evaluated by Dr. Carrington in Jan 2018 at Biloxi VA. Patient c/o of itching and burning of skin when he goes out in the sun and then breaks out in a rash." "Pertinent findings examining the patient's head, neck, face, ears, chest, back, arms and legs, eyelids and lips, the patient has slightly pigmented papular scars on their posterior aspect of the left shoulder. I do not see any other rash or lesions on the chest, back or buttock region. Biopsy results from left upper arm in Jan 21018 revealed confluent and reticulated papillomatosis. Fungus stains were negative. Patient was put on Minocin 100 mg twice a day for 3 months." By July 2018, the Veteran was diagnosed with reticulated papillomatosis. In opining that the reticulated papillomatosis is not related to the Veteran's Gulf War service, the examiner stated the following: Reticulated papillomatosis- as per Dermatologist note dated 10 July 2018 (Icd10 code: L83). No functional limitation. Normal skin examination currently- pictures submitted. Veteran has claimed a disability pattern related to (skin condition, Tinea versicolor, burning sensation of skin) that meets TL10-01 criteria for a disease with a clear and specific etiology and diagnosis. Not caused by or related to GW environmental exposure. Not caused by or related to service. Not caused by episodes of dermatitis due to hot weather in 2009 or dermatophytosis in 2011 and 2012 (this are very different conditions)- no medical literature was found that support this nexus. There is no current evidence of Tinea versicolor- pathology report dated 1/30/2018 is inconsistent with this diagnosis ("Fungal hyphae not identified"). As per medical literature- etiology of condition is multifactorial- "a disorder of keratinization resulting in a hyperproliferative state. Electron microscopy (EM) of the affected skin shows alteration of cornified cell structures, an increased number of lamellar granules in the granular layer, and increased melanosomes in the horny layers [4]. In another EM study, an increased number of transitional cells between stratum corneum and stratum granulosum were noted [5]. Furthermore, in one study with siblings with CARP, increased expression of keratin 16 was demonstrated in focal areas of stratum granulosum [6]. Other genetic factors may also, at least in some part, contribute to the development of CARP, as several other familial cases have been reported [7-10]." While the Board concedes that the medical opinion at hand is quite researched and contains a through rationale, it nevertheless slightly misses the mark for claims involving Gulf War environmental exposure. In Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018), the United States Court of Appeals for Veterans Claims (CAVC) held that a chronic multi-symptom illness is a medically unexplained chronic multi-symptom illness (MUCMI) where either etiology or pathophysiology of the illness is inconclusive. Conversely, an illness is not a MUCMI where both the etiology and pathology are partly understood. Furthermore, the determination of whether an illness is a MUCMI is to be done on a case-by-case basis. That is to say, the question is not whether the illness at hand generally is considered a MUCMI, but whether the illness in the veteran at hand is a MUCMI. Id. at 392. As the examiner noted, the "etiology of [reticulated papillomatosis] is multifactorial," and he discussed various causes. That, however, falls short of the question that needs answering. As Stewart instructs, the Board need ascertain whether the diagnosis of reticulated papillomatosis, as it pertains to this Veterannot generally within the medical communityhas an inconclusive etiology or pathophysiology. See ibid. Because the examiner failed to answer that question, remand is required to ensure that the Board adequately addresses the Veteran's proposed theory of entitlement. See 38 C.F.R. § 20.904(a). 8. Entitlement to service connection for residuals of bilateral gynecomastia is remanded. The Veteran argues that the medication he takes for his skin disability has caused his gynecomastia. E.g., Tr. at 3. Because the issue of entitlement to service connection for a skin disability is being remanded for further development, this issue is considered inextricably intertwined and requires remand. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). 9. Entitlement to TDIU is remanded. Because the Board has awarded the Veteran service connection for tinnitus and several increased ratings, as well as remanded various claims, it is unclear what his overall disability picture will be over the pendency of this appeal. Thus, this claim also inextricably is intertwined, and the AOJ should be permitted to readjudicate the Veteran's claim considering his new awards and any awards it may grant on remand. See ibid. The matters are REMANDED for the following action: 1. Obtain any ongoing VA treatment records. Should they exist, associate them with the claims file. 2. Obtain the Veteran's audiological treatment notes and/or examinations from the Pensacola Naval Hospital. If, after reasonable attempts have been made, those records cannot be obtained, then notify the Veteran as such in accordance with 38 C.F.R. § 3.159(e). 3. Obtain an addendum opinion for the Veteran's skin disability. The addendum shall answer the following: Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's skin disability (currently diagnosed as reticulated papillomatosis) is a medically unexplained chronic multi-symptom illness with either inconclusive etiology or pathophysiology? In answering this question, the examiner must limit the discussion to the Veteran's specific case of reticulated papillomatosis, and not to as it pertains to the medical community at large. Note: The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. A detailed rationale supporting the examiner's opinions must be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 4. Conduct any other development deemed necessary and then readjudicate the Veteran's claims. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded for additional development or other appropriate action by the Board or the CAVC must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Trevor T. Bernard, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.