Citation Nr: 21068937 Decision Date: 11/16/21 Archive Date: 11/16/21 DOCKET NO. 17-30 550 DATE: November 16, 2021 ORDER Entitlement to an initial compensable rating for scarring of the left and right forearms is denied. New and material evidence has been received to reopen the claim of entitlement to service connection for a right wrist disability, and the request to reopen is granted. REMANDED Whether new and material evidence has been received to reopen the claim of entitlement to service connection for left foot pes planus is remanded. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for right foot pes planus is remanded. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left ankle disability is remanded. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right ankle disability is remanded. Entitlement to a compensable rating for pseudofolliculitis barbae is remanded. Entitlement to service connection for a right wrist disability is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a skin condition is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left foot disability, other than pes planus, is remanded. Entitlement to service connection for a right foot disability, other than pes planus, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The scars on the Veteran's left and right forearms are not on his head, face, or neck; are not associated with underlying soft tissue damage; do not cover at least 144 square centimeters; are not painful or unstable; and do not result in functional impairment. 2. The appellant has submitted evidence that was not previously submitted, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right wrist disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for scarring of the left and right forearms have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a right wrist disability. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2000 to May 2005. This matter comes before the Board on appeal from an October 2015 Regional Office (RO) rating decision. The Board has recharacterized the Veteran's claim of entitlement to an increased rating for upper extremity scarring to more accurately reflect that the scarring at issue is on both upper extremities rather than just on his right elbow. The Board notes that the Veteran worked in Afghanistan in a civilian capacity following his military service. Service connection cannot be granted for any Persian Gulf exposures that were incurred during this period of time. However, the Veteran does have qualifying military service to be considered a Persian Gulf veteran under 38 C.F.R. § 3.317(e) for purposes of entitlement to presumptive service connection based on exposures while serving in the Persian Gulf. REFERRED On August 5, 2021, VA issued an interim final rule for respiratory conditions due to exposure to particulate matter. The regulations became effective on August 5, 2021. The final interim rule establishes presumptive service connection for asthma, rhinitis, and sinusitis, to include rhinosinusitis. Specifically, the added 38 C.F.R. § 3.320 states that diseases listed (asthma, rhinitis, and sinusitis, to include rhinosinusitis) shall be service connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service. See 86 Fed. Reg.42733 (August 5, 2021). In the case at hand, the record suggests that the Veteran's claimed headaches may be due to chronic sinusitis. (See September 2015 VA headaches examination report.) Specifically, the Veteran's VA headaches examination report notes a "significant diagnostic test finding[] and/or result[]" of a "Head CT [that] was positive for chronic sinusitis." In addition, the examiner stated that "headache conditions while not formally diagnosed are likely migraine or sinus headaches given the history and examination." Given the new regulations, the issue of entitlement to service connection for sinusitis has been raised and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. Increased Rating 1. Entitlement to an initial compensable rating for scarring of the left and right forearms is denied. Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. During the pendency of this appeal, the rating criteria for scars were amended in August 2018. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the Veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. Effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118 (2018). The Veteran's scarring is not rated under any of these diagnostic codes. The Veteran's left and right forearm scars are assigned a 0 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7802. This diagnostic code applies to burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. A 10 percent rating is assigned when such scars cover an area or areas of 144 square inches (929 square centimeters) or greater. A noncompensable rating is assigned when such scars cover a smaller area. In the case at hand, the Veteran's left and right forearm scars do not cover an area or areas of 144 square inches (929 square centimeters) or greater. (See September 2015 VA scars/disfigurement examination report.) Therefore, entitlement to an initial compensable rating is not warranted under Diagnostic Code 7802. The Board has considered whether a compensable rating is warranted under a different diagnostic code. Diagnostic Codes 7800 through 7805 pertain to scars. Diagnostic Code 7800 does not apply, as it pertains to scars or other disfigurement of the head, face, or neck. Diagnostic Code 7801 does not apply, as it pertains to scars with underlying soft tissue damage. The September 2015 VA scars/disfigurement examination report expressly describes the scars at issue as "superficial," and there is no soft tissue damage. There is no Diagnostic Code 7803. Diagnostic Code 7804 applies to scars that are unstable or painful. It assigns a 10 percent rating when one or two such scars are unstable or painful, and higher ratings are warranted for greater numbers of painful or unstable scars. The September 2015 VA scars/disfigurement examination report expressly states that none of the Veteran's scars is painful or unstable. Neither the Veteran's medical records nor the April 2020 statement from his accredited representative notes that either of these scars is painful or unstable. Therefore, an increased rating is not warranted under Diagnostic Code 7804. Finally, Diagnostic Code 7805 directs that other disabling effects from the scars be rated under other appropriate diagnostic codes. The September 2015 VA scars/disfigurement examination report expressly notes that there is no functional impairment due to these scars, and no such impairment is noted in the Veteran's medical records or asserted by his accredited representative in her April 2020 statement. Therefore, assignment of a compensable rating under Diagnostic Code 7805 is not warranted. In short, entitlement to a compensable rating for left and right forearm scars is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Service Connection Rating actions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. A final decision cannot be reopened unless new and material evidence is presented or secured with respect to that claim. See 38 U.S.C. § 5108; see also Knightly v. Brown, 6 Vet. App. 200 (1994). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The question of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court has held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. It was further noted that reopening a claim only to deny it without providing assistance would be a hollow, technical decision and that there was no reason to expend agency resources on a semantic determination that is not tied to a meaningful procedural duty. Id. at 123-24. A final denial on one theory is a final denial on all theories. Thus, a new theory in support of a claim for a particular benefit is not equivalent to a separate claim. See Ashford v. Brown, 10 Vet. App. 120 (1997). As such, new and material evidence is necessary to reopen a claim for the same benefit asserted under a different theory. See Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a veteran must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a right wrist disability, and the request to reopen is granted. The claim of entitlement to service connection for a right wrist disability was previously denied in an October 2008 rating decision based on the finding that, "Although there is a record of treatment in service for right wrist strain, no permanent residual or chronic disability subject to service connection is shown by the service medical records or demonstrated by evidence following service." At the time of the rating decision, the record contained the Veteran's service treatment records. It also contained a September 2008 VA examination report that noted the presence of right wrist pain but diagnosed no current right wrist disability. The Veteran was notified of this decision in October 2008 and neither initiated an appeal nor submitted new and material evidence within one year of this notice. Therefore, new and material evidence is required to reopen this claim. Since the March 2015 rating decision, new and material evidence has been added to the record in the form of VA medical records reflecting that the Veteran has been treated for additional right wrist complaints. Specifically, a December 2014 VA medical record reflects that the Veteran was fitted for a "Non-custom wrist hand orthosis" for the right wrist. He had noted right wrist shakiness and some numbness and tingling "particularly when working on computer," and he was also noted as having wrist pain. The assessment was "carpal tunnel." A January 2017 VA medical record notes that the Veteran has been diagnosed with carpal tunnel syndrome. This evidence is new in that it was not of record at the time of the prior decision. It is material in that it indicates the presence of a current right wrist disability. Evidence of such a disability was not of record at the time of the prior rating decision. Therefore, new and material evidence having been received, the claim is reopened. To this extent, the claim is granted. It will be considered on the merits in the remand section below. REASONS FOR REMAND 1. Entitlement to a compensable rating for pseudofolliculitis barbae is remanded. In an April 2020 statement, the Veteran's accredited representative requested that this claim be remanded for a new VA examination, "particularly in light of inconsistencies in previous examinations. For example, one examination provides that this condition causes of functional impairment while another reads that he has required at least one day off work." The Board notes that the most recent VA skin diseases examination was in September 2015. The Board further notes that the amendments to the rating criteria that were referenced when discussing the left and right forearm claims above took effect almost three years after the most recent VA examination. The changes in the rating criteria do apply to this claim. For these reasons, the Board finds it necessary to remand this claim for a new VA examination. Given that the appeals period requires VA to evaluate the Veteran's pseudofolliculitis barbae pursuant to the rating criteria that were in effect both before and after August 13, 2018, the examiner should be given the rating criteria that were in effect both before and after August 13, 2018, and should be asked to provide responses that address both sets of criteria. 2. Entitlement to service connection for a right wrist disability is remanded. As noted above, the Veteran has been diagnosed with carpal tunnel syndrome. (See January 2017 VA medical record.) His service treatment records reflect that he sought treatment in August 2002 for right hand pain of one month's duration. It was noted that he has a history of trauma when a radio fell on his "hand and thumb and index metacarpals." The assessment was "[right] wrist pain [rule out] scaphoid [fracture]." The Veteran noted on an October 2002 post-deployment health assessment that "My wrist was badly injured during this deployment. From time to time it hurts when put under certain pressure." The Veteran noted on his April 2005 separation medical history report that "In Kosovo, I had a radio, Singer fall on my right wrist," and that "When I had the fallen radio in Kosovo land on my wrist it was fractured and I was put in a cast for 2 months." The medical provider noted on the April 2005 separation report that the Veteran "had Singer radio fall on [right] wrist [treated with] cast for 2 [months]. X-ray neg[ative] for [fracture] happened in 2002 in Kosovo." The medical provider also noted that there was "no obvious joint bone deformity to wrist." Given that the Veteran has a current carpal tunnel syndrome diagnosis, the Board finds it necessary to remand this claim so that the Veteran may undergo a VA examination and an opinion may be obtained. 3. Entitlement to service connection for headaches is remanded. On August 5, 2021, VA issued an interim final rule for respiratory conditions due to exposure to particulate matter. The regulations became effective on August 5, 2021. The final interim rule establishes presumptive service connection for asthma, rhinitis, and sinusitis, to include rhinosinusitis. Specifically, the added 38 C.F.R. § 3.320 states that diseases listed (asthma, rhinitis, and sinusitis, to include rhinosinusitis) shall be service connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service. See 86 Fed. Reg.42733 (August 5, 2021). As noted in the "REFERRED" section above, given the above regulatory changes, the Board has referred a claim of entitlement to service connection for sinusitis for initial review by the AOJ. The record suggests that the Veteran's claimed headaches may be due to chronic sinusitis. (See September 2015 VA headaches examination report.) Specifically, the Veteran's VA headaches examination report notes a "significant diagnostic test finding[] and/or result[]" of a "Head CT [that] was positive for chronic sinusitis." In addition, the examiner stated that "headache conditions while not formally diagnosed are likely migraine or sinus headaches given the history and examination." Given that the issue of entitlement to service connection for sinusitis has been referred to the AOJ for initial adjudication, the Board will remand the claim of entitlement to service connection for headaches for further consideration following adjudication of the sinusitis issue. 4. Entitlement to service connection for a skin condition is remanded. The claim of entitlement to service connection for a skin condition involves contentions of entitlement to service connection based on Persian Gulf exposures. Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). In the case at hand, the Veteran's post-service treatment records include multiple notations of "Tinea pedis," "Onychomycosis," and "Pruritic rash" on the list of active medical problems. (See, e.g., January 2017 VA medical record.) While tinea pedis and onychomycosis are diagnoses, an opinion is required with respect to whether the "pruritic rash" is a symptom of an undiagnosed illness. In addition, a June 2003 service treatment record notes that the Veteran sought treatment for a rash of three days' duration on his arms and legs. It was noted that the rash was itching. The Veteran reported the rash is more noticeable after showers and that it is getting worse. No diagnosis was given. The Veteran underwent a VA skin diseases examination in September 2015. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed pseudofolliculitis. No other diagnoses or notation of pruritic rash was made. A remand is required so that the Veteran may undergo an examination and an etiology opinion may be obtained with respect to the pruritic rash as well as the diagnosed tinea pedis and onychomycosis. 5. Entitlement to service connection for tinnitus is remanded. The Veteran contends that he has tinnitus due to in-service acoustic trauma. The Veteran underwent a VA hearing loss and tinnitus examination in September 2015, and the resulting examination report found that the Veteran's "tinnitus is at least as likely as not (50% probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss." The examiner also stated that the Veteran's tinnitus is less likely than not caused by or a result of military noise exposure. In the rationale, the examiner noted that "Pure tone air conduction thresholds [were] obtained from 500-6K Hz. 4/00, 1/01, 4/02, 5/10, and 10/12. All WNL [within normal limits] bilaterally except for mild loss (30 dB) recorded bilaterally at 6K Hz. only and on the 2012 test only." The examiner noted that "There were no significant positive threshold shifts between 1K and 4K Hz. in service and none at 6K when factoring in today['] exam, where thresholds were WNL through 8K right and 6K left." The examiner also noted that "It's now been 10 years since the veteran's period of active service. No mention of tinnitus in VBMS." The Board notes that this etiology opinion both (1) attributes the Veteran's tinnitus to hearing loss and (2) states that the Veteran does not have hearing loss. In addition, contrary to the September 2015 opinion, the Veteran's medical records do, in fact, include records in which it is noted that the Veteran has tinnitus. (See, e.g., December 2014 and January 2015 VA medical records.) The Board further notes that the VA examination report does not discuss the Veteran's in-service noise exposure. Specifically, the record reflects that the Veteran served in combat. (See the Veteran's DD Form 214, which notes his receipt of a "Combat Patch.") This record reflects that his Military Occupational Specialty (MOS) was "Cable Systems Installer-Maintainer," and that he had also earned a "Driver and Mechanic Badge with Driver-W Bar." The Veteran's service treatment records contain a January 2001 Reference Audiogram and Hearing Conservation Data forms dated in April 2002, April 2003, and May 2005. The Reference Audiogram notes that the Veteran is "Routinely Noise Exposed, See 1H Report for Noise Levels, H-1." The April 2002 and April 2003 Hearing Conservation Data forms reflect that the Veteran was "Routinely Noise Exposed, H-1," for which he was provided "Hand Formed Earplugs." The May 2005 record notes "Steady Noise Exp(TWA dBA). Not Entered, Impulse Noise Exp(dBP); Not Entered, H-1." It was noted that he was given "Hand Formed Earplugs." In an April 2020 statement, the Veteran's accredited representative noted the Veteran's "exposure to combat, including mortars, IEDs, gunfire, and the like." She also noted that the Veteran has reported an in-service onset of his tinnitus. The Veteran's in-service noise exposure was not discussed in the September 2015 VA examination report. The Board finds it necessary to remand this issue for a new examination and opinion that addresses the above concerns. 6. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for left foot pes planus is remanded. 7. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for right foot pes planus is remanded. 8. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left ankle disability is remanded. 9. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right ankle disability is remanded. 10. Entitlement to service connection for a back disability is remanded. 11. Entitlement to service connection for a left foot disability, other than pes planus, is remanded. 12. Entitlement to service connection for a right foot disability, other than pes planus, is remanded. The Veteran's theories of entitlement to service connection for disabilities of the back, the left foot, and the right foot are essentially the same. In essence, the Veteran contends that wear and tear from his in-service duties, in particular his wearing of Interceptor Body Armor, led to disabilities of the back, left foot, and right foot. Specifically, as noted by the Veteran's accredited representative in an April 2020 statement, the Veteran's "exit examination includes his statements that he suffered from back and foot pain that began during his time in the army. When explaining his back pain, he wrote that 'the worst was in Iraq because of the weight of the [Interceptor Body Armor].'" The representative noted that "These remarks provide competent and credible evidence that [the Veteran's] foot and back problems onset during service." She further stated that the Veteran "is entitled to an examination and opinion to determine a relationship between his feet and ankle pains." The Veteran's service treatment records contain an April 2000 enlistment examination report that notes mild, asymptomatic pes planus of the feet. Also, service treatment records contain an April 2005 separation medical history report in which the Veteran reported that "I have had back pain throughout my military career only in the Army. Sometimes it will last for 2-3 weeks and then go away for a couple of months. It all depends on what activity I do. The worst was in Iraq because of the weight of the IBA." He also reported that "If I run for a certain period of time my feet hurt. I have bunion problems." The provider noted at that time that the Veteran "complained of chronic LBP [low back pain]" and that he "had never seen HCP for this complaint." It also notes that the Veteran has "subjective bilat[eral] foot pain [and has] never seen HCP for this complaint. No documentation." The record contains current complaints of back and foot symptoms. In terms of current disability, the Board notes that a December 2015 VA medical record notes that the Veteran reported back pain. A January 2015 VA medical record notes that the Veteran has pain in both heels with no history of trauma and notes an assessment of heel spur syndrome. At that time, he was fitted for non-custom foot orthotics. An April 2015 VA medical record noted an active medical problem of "fasciitis." A June 2015 VA medical record notes that x-rays showed a small calcaneal spur and includes an assessment of heel spur syndrome and bursitis. October 2015 records note calluses on pressure points of the feet. At this time, there is no new and material evidence to reopen the claims for service connection for pes planus and ankle disabilities. At the time of the prior October 2008 rating decision, the record already contained the Veteran's in-service complaints of foot symptoms. The record also contained the Veteran's description of the strain that his body was under especially when he was wearing his IBA. Current medical records contain no complaints concerning or treatment of the Veteran's left or right ankle. Given the above, however, and in light of diagnoses of the feet other than pes planus, the Board finds it necessary to remand these claims for a VA examination and limited opinion. 13. Entitlement to service connection for GERD is remanded. As noted by the Veteran's representative in an April 2020 statement, the September 2015 VA esophageal conditions examination report notes that the Veteran's "GERD conditions are likely due to job stress, dietary indiscretion or overuse of pain medication." The Board notes that, in its description of the pertinent medical history, this opinion does not mention that the Veteran sought treatment in June 2003 for indigestion that he had been experiencing for three days. The Veteran reported that "carbonated beverages cause indigestion." He was assessed as having "possible indigestion" and was "instructed to stop drinking carbonated bev[erages]." The Board notes that the examination report was focused on the theory of entitlement based on the Veteran's Gulf War service. On remand, an examination should be conducted and an etiology opinion should be obtained with respect to a direct service connection theory of entitlement, based on the manifestation of indigestion during service. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran's records were last obtained. 2. Schedule the Veteran for a VA examination to determine the current severity of his pseudofolliculitis barbae. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. Given that the appeals period requires VA to evaluate the Veteran's pseudofolliculitis barbae pursuant to the rating criteria that were in effect both before and after August 13, 2018, the examiner should be given the rating criteria that were in effect both before and after August 13, 2018, and should be asked to provide responses that address both sets of criteria. 3. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current right wrist disability. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current disabilities of the right wrist. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability had its onset in or is otherwise etiologically related to his military service. In providing this opinion, the examiner should discuss the Veteran's reported mechanism of injury: Specifically, the Veteran contends that he has a current right wrist disability that is due to an in-service injury. The Veteran's service treatment records reflect that he sought treatment in August 2002 for right hand pain of one month's duration. It was noted that he has a history of trauma when a radio fell on his "hand and thumb and index metacarpals." The assessment was "[right] wrist pain [rule out] scaphoid [fracture]." The Veteran noted on an October 2002 post-deployment health assessment that "My wrist was badly injured during this deployment. From time to time it hurts when put under certain pressure." The medical provider also noted that there was "no obvious joint bone deformity to wrist." The Veteran noted on his April 2005 separation medical history report that "In Kosovo, I had a radio, Singer fall on my right wrist," and that "When I had the fallen radio in Kosovo land on my wrist it was fractured and I was put in a cast for 2 months." The medical provider noted on the April 2005 separation report that the Veteran "had Singer radio fall on [right] wrist [treated with] cast for 2 [months]. X-ray neg[ative] for [fracture] happened in 2002 in Kosovo." Is there any medical reason to accept or reject the proposition that the claimed mechanism of injury caused any current right wrist conditions? Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 4. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current skin disabilities (other than pseudofolliculitis barbae and forearm scarring, for which service connection is already in effect). The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. Because they have been listed in the Veteran's VA medical records as active medical problems during the course of the appeals period, the examiner's opinion should address the Veteran's "pruritic rash," tinea pedis, and onychomycosis. The examiner should determine whether the Veteran has skin symptoms that cannot be attributed to a known clinical diagnosis. If the examiner determines that the Veteran has had skin symptoms that cannot be attributed to a known clinical diagnosis, the examiner must indicate whether it is at least as likely as not (50 percent probability or greater) that the Veteran's symptoms are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness etiologically related to his service in Southwest Asia. If the examiner determines that the Veteran has had a diagnosed skin condition, the examiner must indicate whether it was at least as likely as not (50 percent probability or greater) etiologically related to his military service or his service in Southwest Asia. In providing this opinion, the examiner should discuss the June 2003 service treatment record noting that the Veteran sought treatment for a rash of three days' duration on his arms and legs. It was noted that the rash was itching. The Veteran reported the rash is more noticeable after showers and that it is getting worse. No diagnosis was given. Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 5. Schedule the Veteran for an examination by an examiner with sufficient expertise to determine whether the Veteran has a current tinnitus disability and, if so, the etiology of any such disability. The claims file must be made available to and reviewed by the examiner, and a complete history should be obtained from the Veteran. Any indicated studies should be performed, and all findings should be reported in detail. If tinnitus is diagnosed, the examiner should opine as to whether such disability is at least as likely as not (a 50 percent probability or greater) etiologically related to service, to include his in-service noise exposure. The Board notes that the September 2015 VA hearing loss and tinnitus examination report opined that the Veteran's tinnitus is due to his hearing loss but also found that the Veteran does not have a hearing loss disability for VA purposes. The Board notes that, if a hearing loss disability is not diagnosed, an opinion linking tinnitus to nonexistent hearing loss will be considered to be inadequate. Given the Veteran's combat service, his reports of in-service noise exposure are considered to be credible. The record reflects that the Veteran served in combat. (See the Veteran's DD Form 214, which notes his receipt of a "Combat Patch.") This record reflects that his Military Occupational Specialty (MOS) was "Cable Systems Installer-Maintainer," and that he had also earned a "Driver and Mechanic Badge with Driver-W Bar." The Veteran's service treatment records contain a January 2001 Reference Audiogram and Hearing Conservation Data forms dated in April 2002, April 2003, and May 2005. The Reference Audiogram notes that the Veteran is "Routinely Noise Exposed, See 1H Report for Noise Levels, H-1." The April 2002 and April 2003 Hearing Conservation Data forms reflect that the Veteran was "Routinely Noise Exposed, H-1," for which he was provided "Hand Formed Earplugs." The May 2005 record notes "Steady Noise Exp(TWA dBA). Not Entered, Impulse Noise Exp(dBP); Not Entered, H-1." It was noted that he was given "Hand Formed Earplugs." In an April 2020 statement, the Veteran's accredited representative noted the Veteran's "exposure to combat, including mortars, IEDs, gunfire, and the like." She also noted that the Veteran has reported an in-service onset of his tinnitus. Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 6. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current back and left and right foot disabilities. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current disabilities of the back, the left foot, and the right foot. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability had its onset in or is otherwise etiologically related to his military service. In providing this opinion, the examiner should discuss the Veteran's reported mechanism of injury: In essence, the Veteran contends that wear and tear from his in-service duties, in particular his wearing of Interceptor Body Armor, led to disabilities of the back, left foot, and right foot. The Veteran's service treatment records reflect that he reported back and foot pain on his April 2005 separation medical history report. With respect to his back, the April 2005 record notes that the Veteran reported that "I have had back pain throughout my military career only in the Army. Sometimes it will last for 2-3 weeks and then go away for a couple of months. It all depends on what activity I do. The worst was in Iraq because of the weight of the IBA [Interceptor Body Armor]." The medical provider noted at that time that the Veteran "complained of chronic LBP [low back pain]" and that he "had never seen HCP for this complaint." With respect to his left and right feet, the April 2005 separation medical history report notes that the Veteran reported that "If I run for a certain period of time my feet hurt. I have bunion problems." The medical provider notes that the Veteran has "subjective bilat[eral] foot pain [and has] never seen HCP for this complaint. No documentation." Is there any medical reason to accept or reject the proposition that the claimed mechanism of injury caused any current back, left foot, or right foot conditions? Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 7. Arrange for the Veteran to undergo an examination to determine the nature and etiology of his current GERD. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) etiologically related to his military service. In providing this opinion, the examiner should discuss the June 2003 service treatment record reflecting that he sought treatment for indigestion that he had been experiencing for three days. The Veteran reported that "carbonated beverages cause indigestion." He was assessed as having "possible indigestion" and was "instructed to stop drinking carbonated bev[erages]." Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 8. The issue of entitlement to service connection for sinusitis has been referred for initial AOJ adjudication, above. Following adjudication of that claim, readjudicate the claim of entitlement to service connection for headaches, to include as due to sinusitis. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.