Citation Nr: 21064972 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 16-18 935 DATE: October 22, 2021 ORDER Entitlement to a disability rating higher than 10 percent for limitation of motion associated with the service-connected right knee disability is denied. For the entire period, entitlement to a separate rating of 10 percent, but not higher, for lateral instability associated with the service-connected right knee disability is granted. Prior to December 14, 2020, entitlement to a disability rating higher than 10 percent for limitation of motion associated with the service-connected left knee disorder is denied. Since December 14, 2020, entitlement to a disability rating higher than 20 percent for limitation of motion associated with the service-connected left knee disorder is denied. For the entire period, entitlement to a separate rating of 10 percent, but not higher, for lateral instability associated with the service-connected left knee disability is granted. REMANDED Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for scars is remanded. Entitlement to service connection for a sleep disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The service-connected right knee disability is manifested by painful motion with full extension, flexion limited to more than 30 degrees, slight lateral instability, and without significant meniscal pathology. 2. Prior to December 14, 2020, the service-connected left knee disorder was manifested by painful motion with full extension, flexion limited to more than 30 degrees, slight lateral instability, and without significant meniscal pathology. 3. Since December 14, 2020, the service-connected left knee disorder is manifested by painful motion with full extension, flexion limited to more than 15 degrees, slight lateral instability, and without significant meniscal pathology. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating higher than 10 percent for limitation of motion associated with the service-connected right knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5256-5262. 2. For the entire period, the criteria for entitlement to a disability rating of 10 percent for lateral instability associated with the service-connected right knee disability are met; the criteria for a rating higher than 10 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. Prior to December 14, 2020, the criteria for entitlement to a disability rating higher than 10 percent for limitation of motion associated with the service-connected left knee disability were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5256-5262. 4. Since December 14, 2020, the criteria for entitlement to a disability rating higher than 20 percent for limitation of motion associated with the service-connected left knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5256-5262. 5. For the entire period, the criteria for entitlement to a separate rating of 10 percent for lateral instability associated with the service-connected left knee disability are met; the criteria for a rating higher than 10 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from August 2004 to July 2014. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2021 Order of the United States Court of Appeals for Veterans Claims (Veterans Court). The appeal originates from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In March 2019, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e). At the Board hearing, the Veteran was informed of the basis for the RO's denial of his claims, and he was informed of the information and evidence necessary to substantiate each claim. 38 C.F.R. § 3.103. A transcript of the hearing is associated with the claims file. In April 2020, the Board remanded the service connection issues for additional evidentiary development. The appeal has since been returned to the Board for further appellate action. The Board also dismissed a rating claim for tinnitus, granted service connection for a bowel disorder, denied service connection for a mental disorder, acne, and a skin disorder, and remanded service connection for a left ankle disorder. On remand, VA granted service connection for a left ankle disorder, resolving that appeal. The Board's decision with respect to issues decided is final. See 38 C.F.R. § 20.1100. VA has subsequently granted service connection for a mental disability. The Veteran appealed that decision to the Veterans Court. In a May 2021 Order, pursuant to a Joint Motion for Remand, the Veterans Court vacated the Board's decision regarding service connection for acne, keloids, and sleep impairment, and remanded those issues to the Board for additional development consistent with the Joint Motion. The issue of TDIU entitlement was not separately appealed but is being considered here as a component of the increased rating claims in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). The Veteran revoked his attorney representative in March 2021 and is currently pro se in this appeal. Increased RatingsLaw and Regulations Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, supra; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Under Diagnostic Code 5256 ankylosis is rated 60 percent where it is extremely unfavorable, in flexion at an angle of 45 degrees or more; a rating of 50 percent where in flexion between 20 degrees and 45 degrees; a rating of 40 percent where in flexion between 10 degrees and 20 degrees; and a rating of 30 percent where at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Since February 7, 2021, under Diagnostic Code 5257, other impairment of the knee can be rated on the basis of either recurrent subluxation or lateral instability, or on the basis of patellar instability. Where a rating is assigned on the basis of recurrent subluxation or lateral instability, a rating of 30 percent if there is an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A rating of 20 percent is assigned with one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A rating of 10 percent for a sprain, incomplete ligament tear, or complete ligament tear repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Where a rating is assigned on the basis of patellar instability, a rating of 30 percent is assigned where there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A rating of 20 percent is assigned with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker . A rating of 10 percent is assigned with a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Prior to February 7, 2021, under Diagnostic Code 5257, recurrent subluxation or lateral instability is assigned a rating of 30 percent if severe, a rating of 20 percent if moderate, or a rating of 10 percent if slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Under Diagnostic Code 5258, a rating of 20 percent is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, symptomatic removal of the semilunar cartilage is assigned a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, limitation of flexion of the knee is assigned a rating of 30 percent where flexion is limited to 15 degrees; a rating of 20 percent where flexion is limited to 30 degrees; a rating of 10 percent where flexion is limited to 45 degrees; or a rating of 0 percent where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee is assigned a rating of 50 percent where extension is limited to 45 degrees; a rating of 40 percent where extension is limited to 30 degrees; a rating of 30 percent where extension is limited to 20 degrees; a rating of 20 percent where extension is limited to 15 degrees; a rating of 10 percent where extension is limited to 10 degrees; or a rating of 0 percent where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5262, impairment of the tibia and fibula is assigned a rating of 40 percent with nonunion, with loose motion, requiring brace. With malunion of tibia and fibula, Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, are to be applied, whichever results in the highest evaluation. For medial tibial stress syndrome (MTSS), or shin splints, a rating of 30 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to surgery and either shoe orthotics or other conservative treatment, both lower extremities; a rating of 20 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to surgery and either shoe orthotics or other conservative treatment, one lower extremity; a rating of 10 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to either shoe orthotics or other conservative treatment, one or both lower extremities; a rating of 0 percent is appropriate with treatment less than 12 consecutive months, one or both lower extremities. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) is assigned a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5263. Entitlement to a disability rating higher than 10 percent for the service-connected right knee disorder. Entitlement to an increased disability rating for the service-connected left knee disorder, currently rated at 10 percent prior to December 14, 2020, and 20 percent since that date. The current appeal arises from a claim of entitlement to service connection for bilateral knee disorders that was received at VA on July 4, 2014. In a July 2014 rating decision, VA granted service connection for right and left knee disorders (patellofemoral syndrome) and assigned initial ratings of 10 percent each under Diagnostic Code 5260, effective July 4, 2014. In a March 2021 decision, VA granted an increased rating 20 percent for the left knee, effective December 14, 2020, the date of a VA examination. The report of VA Knees Examination in July 2014 reveals a diagnosis of patellofemoral syndrome. The Veteran reported that he needs to stretch and reposition frequently. Extreme physical activity is limited due to pain. Range of motion of the right and left knee were identical, from 0 degrees (extension) to 140 degrees (flexion). There was no objective evidence of painful motion. Functional loss consisted of painful motion after repetitive use and interference with sitting. Muscle strength was normal. There was no anterior joint instability, no posterior joint instability, no medial or lateral joint instability, and no subluxation. There was no tibial or fibular impairment. There were no meniscal conditions. There was no impact of the disability on the ability to work (Record 07/02/2014 at 7). A May 27, 2015, Clinical Note reveals the Veteran's complaint of knee pain, which fluctuates in intensity. A problem sheet lists meniscal degeneration (Record 06/11/2015). A July 2015 Knees Examination reveals complaint of pain and that his knees are becoming more unstable. The diagnosis is patellofemoral pain syndrome. Examination of the knees revealed that both knees were normal in flexion, measured to 140 degrees without objective evidence of pain on motion or on weight bearing. After 3 repetitions of flexion, the measurement was unchanged. Extension was measured to 0 degrees with objective evidence of pain. After 3 repetitions of flexion, the measurement was unchanged. The knee was not being tested during a flare. The additional limitation of motion during a flare was unable to be estimated without mere speculation as this is a limited exam and does not indicate real life situations. The knee was not being examined after repeated use over a period of time. The additional limitation of motion after repeated use over a period of time was unable to be estimated without mere speculation as this is a limited exam and does not indicate real life situations.to be. Muscle strength was normal. There was no anterior joint instability, no posterior joint instability, no medial or lateral joint instability, and no subluxation. There was no tibial or fibular impairment. There were no meniscal conditions. The conditions impact the Veteran's ability to stand, walk, lift, and sitting for prolonged periods of time. He has difficulty bearing weight at times, especially during flare-ups (Record 07/30/2015). The Veteran submitted physical therapy records from November 20, 2015, February 12, 2016, reflecting physical therapy for the Veteran's knee pain (Record 05/20/2019). A November 2018 MRI of the left knee shows a small osteochondral defect of the medial femoral condyle; slight lateral patellar tilt, mild heterogeneity of the patellar cartilage with no discrete anterior compartment cartilage loss; and intact extensor mechanism with mild distal quadriceps tendinosis (Record 02/18/2019). A December 21, 2018, VA Primary Care Note reveals complaint of knee pain. However, on examination, range of motion was intact. An MRI of the knees shows no significant findings (Record 03/14/2019 at 10). A February 12, 2019, Polytrauma Note reveals bilateral knee pains since 2012 secondary to wear-and tear, popping and cracking and feeling unstable. Current pains mild with exacerbations throughout the week depending on activities. Pains can last up to a few hours. However, testing of knee range of motion was normal (Record 03/14/2019 at 5). A March 12, 2019, VA Primary Care Note reveals complaint of knee pain. However, X-rays were normal; and examination of the knees was within normal limits in terms of flexion and extension as well as muscle strength. Testing for instability was mixed, with negative results for anterior and posterior drawer, and Apley's grind test, and positive for varus and valgus stress (Record 03/14/2019 at 2). In May 2019, B. Christensen FNP-C reported left knee flexion to 78 degrees, and right knee flexion to 75 degrees, with severe sharp pain. The examiner suggested a 60 percent under 5256 (ankylosis). Extension was measured to 10 degrees, bilaterally, with severe sharp pain. The examiner suggested a 10 percent rating under 5261 (Record 05/20/2019). A September 17, 2019, VA physical therapy note reveals the Veteran's complaint of instability of the left knee (Record 07/30/2020 at 20). A VA joints examination in December 2020 reveals the Veteran's complaint of difficulty with standing/walking and sitting especially when driving for extended periods of time, picking up heavy objects off the floor, and certain movements. He reported difficulty playing sports or engaging in some recreational and occupational activities requiring lifting, standing, and walking extended periods. Flares occur few times a week and are moderately severe. They last a few hours and are precipitated by overuse. On examination, the right knee range of motion was from 0 to 40 degrees, and 0 to 20 degrees on the left knee. There was pain with motion, but no pain with weight bearing. There was no additional limitation of motion with repetition. The Veteran was being examined after repetitive use over a period of time, and during a flare, so the measured range of motion was reflective of that. Muscle strength was full, without atrophy. There was no instability, dislocation, subluxation, ankylosis, or meniscal condition. The Veteran regularly uses a knee sleeve for pain. The examiner diagnosed bilateral patellofemoral syndrome (Record 03/09/2021). After a review of all of the evidence, the Board finds that the criteria for higher or separate disability ratings are not met. Regarding flexion, testing has been normal for both knees until the May 2019 examination. Indeed, two months prior to the May 2019 examination, flexion and strength were normal, as were X-rays. Testing for the right knee in December 2019 exceeded 30 degrees; therefore, a rating higher than 10 percent is not warranted for the right, or for the left knee prior to December 14, 2020. The agency of original jurisdiction appropriately granted a 20 percent rating for the left knee on the basis of flexion; however, even after December 14, 2020, testing exceeded 15 degrees; therefore, a higher rating is not warranted. The Board has considered the suggestion of B. Christensen that a rating for ankylosis is recommended. However, ankylosis is defined as complete bony fixation of a joint. His own report indicates flexion of the right and left knees of 78 and 75 degrees, respectively. This draws into question the examiner's understanding of the term "ankylosis." In any event, ankylosis is not shown or approximated with respect to either knee. The Veteran has demonstrated the ability to flex and extend both knees. With the exception of the examination of B. Christensen, extension has always been full. The examination two months before his examination, and the examination just after his examination showed full extension. Accordingly, the Board considers his results as outliers and not representative of a true worsening of extension. Accordingly, the Board finds that a separate rating for limitation of extension is not warranted for either knee. Regarding lateral instability, the Veteran has reported that his knees feel unstable since the July 2015 report. Diagnostic Code 5257 does not require "objective" medical evidence of lateral instability for a rating to be assigned. Objective medical evidence is not automatically more probative than lay evidence. English v. Wilkie, 30 Vet. App. 347 (2018). While testing for lateral instability has largely been negative, the March 2019 report was positive. With resolution of all reasonable doubt in favor of the claim, the Board finds that a rating of 10 percent is warranted under Diagnostic Code 5257 for each knee. The Board finds no reason to stage the rating, as the Veteran's report in 2015 was that the knees were becoming more unstable. Thus, he reported a process, not a sudden change. Accordingly, the Board finds that the separate ratings should be granted for the period since the July 4, 2014, claim. The Board finds that ratings higher than 10 percent are not warranted for instability. Balanced against any higher ratings are the normal findings for lateral instability on all examinations other than the March 2019 testing, as well as the normal measurements of muscle strength, which certainly affects stability of the joint. Accordingly, the Board finds that moderate instability is not substantiated. Under the amended version of the regulation, there is no diagnosed condition involving the patellofemoral complex and no history of ligament tear or sprain. Regarding meniscal pathology, the evidence does not substantiate such pathology as would warrant a rating under Diagnostic Code 5258 or 5259. There is no history of surgical repair, and the findings for meniscal pathology have been negative. In sum, the Board finds that the criteria for separate ratings of 10 percent each, but not higher, for lateral instability associated with the service-connected disabilities are met. However, the Board finds that the criteria for higher or separate ratings are not met on the basis of limitation of motion or other pathology. In light of these findings of fact, the Board concludes that a disability rating higher than 10 percent for limitation of motion associated with the service-connected right knee disability is not warranted. The Board also finds that, prior to December 14, 2020, a rating higher than 10 percent is not warranted for limitation of motion associated with the service-connected left knee disability, and since December 14, 2020, a rating higher than 20 percent is not warranted for limitation of motion associated with the left knee disability. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Entitlement to service connection for a skin disorder. Entitlement to service connection for scars. On the service entrance examination, the Veteran was noted to have acne of the thorax and shoulders, and a nevus on the upper lip (Record 05/05/2014 at 36). On March 22, 2007, he was noted to have cystic acne on the back and chest. There were also lesions on the shoulders, face, neck, and back. There was moderate inflammation (Record 05/05/2014 at 7). On April 23, 2007, the Veteran was seen with problem list entries of cystic acne, keloid scar and acne (Record 05/05/2014 at 3). A July 20, 2007, Clinical Note reveals that the Veteran had laser surgery to remove acne scars on his chest and back the previous day (Record 07/11/2014 at 43). On August 31, 2007, the Veteran was noted to have a history of acne scars to the chest, shoulders and back with removal by laser (Record 05/05/2014 at 7). A report of medical examination performed at service separation on February 12, 2014, reveals that acne was noted (Record 05/05/2014 at 30). On February 24, 2014, the Veteran reported for his separation physical. He reported no concerns. He was found to be in excellent general overall health. He was noted to have acne keloidalis, a scar, acne, a keloid scar, and cystic acne as chronic problems (Record 05/05/2014). A report of VA General Medical Examination in July 2014 reveals a diagnosis of cystic acne. The examiner noted that the Veteran had a history of cystic acne that was present before enlistment. He also formed keloids from this acne. He was treated with various products including Accutane. "This condition seems to be under control." There was no impact of the condition on his ability to work (Record 07/02/2014). A July 2014 VA Examination Addendum states that acne keloids are often a result of cystic acne and the Veteran developed his first keloid from this disease prior to enlistment. Therefore, "I would consider this a natural progression of a preexisting condition and not aggravated by his service time" (Record 08/27/2014). In April 2020, the Board denied these claims. In the May 2021 Joint Motion, the parties agreed that the VA examination relied upon by the Board was inadequate, and that a new VA examination should be obtained. The basis is that the examiner stated that keloids are often a result of cystic acne and he developed his first keloid from this disease prior to enlistment. The parties agreed that this does not fully describe the significance of the Veteran's acne and keloid scars, and it does not discuss whether the need for surgical treatment of acne was part of its natural progression. The parties agreed that the claims for acne and keloid scars are inextricably intertwined. Entitlement to service connection for a sleep disorder. The parties to the Joint Motion agreed that the Board erred in finding that the Veteran's sleep impairment was not a distinct diagnosis, but was a symptom associated with other life factors. Subsequently, the Veteran submitted a letter dated August 10, 2021, from a private provider at the North Texas Lung & Sleep Clinic. The examiner reported that the Veteran had undergone a sleep study in June 2021. The results of that study are not of record. The examiner diagnosed obstructive sleep apnea, which is defined in terms of a blockage of the airway. https://www.webmd.com/sleep-disorders/sleep-apnea/understanding-obstructive-sleep-apnea-syndrome. The examiner related sleep apnea to the Veteran's mental disability, tinnitus, and pain (Record 08/18/2021). As the nature of the Veteran's conditions appears to be a structural blockage of the airway, the rationale for the purported relationship to a mental disability is not adequately reasoned. The stated rationale is that "studies" (unnamed) have shown that one-third of PTSD patients have obstructive sleep apnea. However, the Board notes that coincidence and causation are not equivalent. The examiner lists tinnitus, knee pain and PTSD as contributing to the Veteran's insomnia and sleep apnea, but does not explain the contribution, nor does the examiner distinguish the Veteran's insomnia from his already-compensated sleep impairment associated with his service-connected mental disability. Accordingly, additional development is necessary to obtain relevant medical records and to obtain an adequate medical opinion. Entitlement to TDIU. The separate issue of TDIU entitlement is inextricably intertwined and the proposed development will encompass that issue. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (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). The matters are REMANDED for the following action: 1. Obtain records from the North Texas Lung & Sleep Clinic, to include the results of a June 21, 2021, sleep study. 2. Schedule an appropriate VA examination to determine the nature and etiology of the Veteran's claimed sleep disorder(s). The relevant documents in the claims file should be made available to the VA examiner. All indicated tests and studies should be accomplished. The VA examiner is requested to report all pertinent diagnoses of sleep disorders and to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that any diagnosed sleep disorder (1) is causally or etiologically related to the Veteran's active service; or (2) is causally or etiologically related to a service-connected disability; or (3) was worsened beyond natural progress by a service-connected disability. 3. Obtain a medical opinion regarding the Veteran's acne and keloid scars. The examiner is asked to review the record, including the service entrance examination, which showed the presence of acne, and the service separation examination, which also showed the presence of acne. The opinion should address whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the occurrence of symptoms in service or the treatment received during service represents a worsening beyond the naturally expected progress of the condition, or whether such symptoms and treatment is in accordance with the natural progress of the condition. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation or worsening as it is to find against causation or worsening. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, the examiner is asked to please provide complete explanations stating why this is so. In so doing, the examiner is asked to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that the examiner has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Readjudicate the remanded claims, to include consideration of extraschedular referral for TDIU, if warranted. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Cramp 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.