Citation Nr: 21070185 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 12-19 166 DATE: November 23, 2021 ORDER Entitlement to service connection for a left knee disability is dismissed. Entitlement to service connection for bilateral pes planus is dismissed. Entitlement to an initial rating in excess of 10 percent for a surgical scar associated with GERD with Mallory-Weiss Syndrome is denied. Entitlement to a rating in excess of 10 percent for GERD with Mallory-Weiss Syndrome is denied. REMANDED Entitlement to service connection for psoriasis, claimed as a result of exposure to Agent Orange is remanded. Entitlement to service connection for psoriatic arthritis, claimed as a result of exposure to Agent Orange is remanded. Entitlement to service connection for testicular cancer, claimed as a result of exposure to Agent Orange is remanded. Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD) and dysthymia, to include as secondary to service-connected GERD with Mallory-Weiss Syndrome is remanded. FINDINGS OF FACT 1. The issue of entitlement to service connection for a left knee disability was granted in a July 2021 rating decision; there is no case or controversy remaining before the Board as to this issue. 2. The issue of entitlement to service connection for bilateral pes planus was granted in a July 2021 rating decision; there is no case or controversy remaining before the Board as to this issue. 3. The Veteran has one surgical scar that is unstable or painful, that is not associated with underlying soft tissue damage greater than 77 square centimeters. 4. The Veteran's GERD with Mallory-Weiss Syndrome did not more nearly approximate symptoms that were productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for dismissal of the appeal seeking service connection for a left knee disability have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 19.55 (2019). 2. The criteria for dismissal of the appeal seeking service connection for bilateral pes planus have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 19.55 (2019). 3. The criteria for entitlement to an initial rating in excess of 10 percent for a surgical scar associated with GERD with Mallory-Weiss Syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7801, 7804 (2019). 4. The criteria for entitlement to a rating in excess of 10 percent for GERD with Mallory-Weiss Syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7346 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to June 1979, including service in Korea between May 1978 and June 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This appeal was previously before the Board in June 2020. Service Connection 1. Entitlement to service connection for a left knee disability 2. Entitlement to service connection for bilateral pes planus The issues of entitlement to service connection for a left knee disability and bilateral pes planus were remanded by the Board in June 2020. Subsequently, in a July 2021 rating decision, service connection was granted for bilateral pes planus and left knee strain with degenerative arthritis. As such, these claims are dismissed as a matter of law, as there remains no case or controversy, or dispute of fact or law, regarding the issue. See 38 U.S.C. § 7105; 38 C.F.R. § 19.55. The benefit sought on appeal was granted. The claims are therefore dismissed. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. 3. Entitlement to an initial rating in excess of 10 percent for a surgical scar associated with GERD with Mallory-Weiss Syndrome The Veteran contends that he is entitled to a higher rating for his surgical scar. The scar is rated under Diagnostic Code 7804 for unstable or painful scar. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran's scar is not manifest by three or four scars that are unstable or painful. The Veteran was afforded a VA stomach and esophageal conditions examination in March 2012. While the Veteran was noted to have a scar, it was indicated that no scar was painful or unstable, or had a total area greater than 39 square cm. The Veteran was afforded a VA scar examination in September 2016. He was noted to have an abdominal surgical scar. It was noted not to be painful, not unstable, without frequent loss of covering of the skin over the scar, and not due to burns. The anterior trunk was the only affected area. It was noted that the Veteran had in fact two linear scars one measuring 0.5 cm, and the other measuring 22 cm. No functional impact was noted. The Veteran was afforded another VA scar examination in April 2021. The Veteran's diagnosis of two scars was confirmed. One scar was noted to be due to Mallory Weiss surgery, and the other was due to testicular removal. One scar was noted to be painful, including mid abdomen pain. No scars were unstable or had frequent loss of covering of skin. The mid abdomen scar was noted to measure 22cm x 2cm. It was also noted to be tender to palpation. Underlying tissue damage was noted in the anterior trunk measuring 44.25 square centimeters. No functional impact was noted. The Board has also considered the other Diagnostic Codes pertaining to scars. The Veteran's scar is not of the head, face, or neck, and is not deep and nonlinear. It is, however, associated with underlying soft tissue damage. Therefore, 38 C.F.R. § 4.118, Diagnostic Code (DC) 7801 is applicable. Prior to August 13, 2018, DC 7801 considered scars that are deep and non-linear, and since August 13, 2018, DC 7801 considers scars associated with underlying soft tissue damage. Under both iterations of DC 7801, qualifying scars warrant a 10 percent rating if the area or areas exceed 6 square inches (39 sq. cm). A 20 percent rating requires an area or areas exceeding 12 square inches (77 sq. cm); a 30 percent evaluation is assigned for an area or areas exceeding 72 square inches (465 sq. cm); and a 40 percent evaluation is warranted for an area or areas exceeding 144 square inches (929 sq. cm). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note 1 (2018). Since August 13, 2018, a separate evaluation may be assigned for each affected zone of the body (each extremity, anterior trunk, and posterior trunk) if there are multiple scars, or a single scar, affecting multiple zones of the body. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this DC. 38 C.F.R. § 4.118, Diagnostic Code 7801, Notes 1-2 (2019). The Board notes that two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. 38 C.F.R. § 4.118(b). In order to achieve an evaluation in excess of 10 percent under DC 7801, the affected area would have to exceed 12 square inches (77 sq. cm). In this regard, the largest area noted of record in VA examinations is 44.25 square centimeters. See April 2021 VA examination. Therefore, a higher evaluation under DC 7801 would not be warranted. Under DC 7804, the Board notes that the next higher evaluation of 20 percent would require three or four scars that are unstable or painful. The Veteran has one painful scar. Therefore, a higher rating under DC 7804 is not warranted either. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. In this regard, no functional impact was reported, nor were any other physical effects noted in the VA examinations of record. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include pain and discomfort, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical records do not show, that the Veteran's scar is manifest by three or four scars that are unstable or painful; or that there is an area of underlying soft tissue damage exceeding 77 square centimeters. In conclusion, the Board finds that the preponderance of the evidence is against the claim for a disability rating in excess of 10 percent for the Veteran's scar disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a rating in excess of 10 percent for GERD with Mallory-Weiss Syndrome The Veteran contends he is entitled to a higher rating for GERD with Mallory-Weiss Syndrome. The Veteran's GERD with Mallory-Weiss Syndrome is rated pursuant to 38 C.F.R. § 4.114, Diagnostic Code (DC) 7304, for a gastric ulcer. When an unlisted condition is encountered, as with GERD, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Conditions relating to the digestive system are evaluated under C.F.R. § 4.114. Certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. See C.F.R. § 4.113. Under C.F.R. § 4.114, the ratings under Diagnostic Codes 7301 to 7329 inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with evaluation to the next higher evaluation where the severity of the overall disability warrants such evaluation. Under DCs 7304 and 7305, severe ulcers (gastric or duodenal) when manifested by pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena with manifestations of anemia and weight loss productive of definite impairment of health and warrant a 60 percent disability rating. A 40 percent disability rating is warranted for moderately severe duodenal ulcers manifested by less than severe but with impairment to health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 20 percent disability rating is warranted for a moderate duodenal ulcer manifested by recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 10 percent disability rating is warranted for a mild duodenal ulcer manifested with recurring symptoms once or twice yearly. Under DC 7346, symptoms of pain, vomiting, material weight loss and hematemesis of melena with moderate anemia; or other symptom combinations productive of severe impairment of health caused by a hiatal hernia warrant a 60 percent disability rating. 38 C.F.R. § 4.114. A 30 percent disability rating is warranted for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 10 percent disability rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. Id. The Veteran was afforded a VA stomach conditions examination in March 2012. The Veteran's diagnosis was confirmed as Mallory-Weiss Syndrome. The Veteran reported experiencing chronic indigestion since his surgery in service. In addition, the Veteran reported experiencing chest pain. Signs and symptoms were noted to include recurring, not severe symptoms, four or more times per year, lasting less than one day; abdominal pain relieved by standard ulcer therapy; and mild nausea once a year. No incapacitating episodes were noted. However, the Veteran was also noted to have hypertrophic gastritis without symptoms or findings and postgastrectomy syndrome characterized by mild, infrequent episodes of epigastric distress with mild circulatory symptoms or continuous mild manifestations. The Veteran was also afforded a VA esophageal conditions examination in March 2012. The Veteran's diagnosis was confirmed as GERD. The Veteran reported having been diagnosed with GERD during active service, and experiencing weekly indigestion with abdominal distress. Signs and symptoms were noted to include persistently recurrent epigastric distress, pyrosis, sleep disturbance four or more times per year, and anemia. While the Veteran was noted to have esophageal stricture, spasm or diverticula, these were noted to be asymptomatic. Other pertinent physical findings included a scar, which is separately addressed. There was no diagnostic testing, nor was any functional impact noted. The Veteran was again afforded a VA esophageal conditions examination in September 2016. The Veteran's diagnosis was confirmed as GERD with Mallory Weiss Syndrome. The Veteran reported experiencing chronic indigestion and chest pain since his Mallory Weiss surgery in service. Signs and symptoms were noted to include pyrosis, reflux, regurgitation, substernal pain, sleep disturbance four or more times per year lasting less than one day and nausea four or more times per year lasting less than one day. No esophageal stricture, spasm or diverticula were noted, and other pertinent physical findings included a scar, which is separately addressed. There was no diagnostic testing, nor was any functional impact noted. The Veteran was afforded another VA esophageal conditions examinations in April 2021. The Veteran's diagnosis was confirmed as GERD. The Veteran reported worsening burning in the , drainage in the throat, and heartburn. There were no signs and symptoms; no esophageal stricture, spasm, or diverticula; and no physical findings. There was no diagnostic testing. Functional impact, however, was noted as difficulty concentrating and focusing on job tasks with a flare up of GERD. The Board finds, first, that the Veteran is not entitled to a rating in excess of 10 percent for his gastrointestinal disability under DCs 7304 and 7305. In this regard, the Board notes that while the Veteran's symptoms throughout the appeal period have included esophageal stricture or obstruction; mild, infrequent episodes of epigastric distress; pyrosis; reflux; regurgitation; substernal pain; sleep disturbance four or more times per year lasting less than one day; anemia and nausea four or more times per year lasting less than one day. these symptoms were not productive of considerable or severe impairment of health. Under DCs 7304 and 7305, a higher 20 percent rating would require recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. In this case, however, neither the March 2012, September 2016 or April 2021 VA examinations reflect severe symptoms lasting ten days or more or continuous moderate symptoms. In fact, the March 2012 examiner indicated that symptom manifestations were mild in nature; the September 2016 VA examiner indicated episodes of sleep disturbance and nausea lasted less than one day; and the April 2021 examiner found no signs or symptoms. Thus, a rating in excess of 10 percent is not warranted under DCs 7304 and 7305. In addition, a higher 30 percent rating under DC 7346 is not warranted. This would require the presence of persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. While the VA examinations throughout the appellate period reflect persistently recurrent epigastric distress, pyrosis and substernal pain none of the VA examiners suggested these were productive of considerable impairment of health. In fact, as previously noted, the March 2012 examiner indicated that symptom manifestations were mild in nature, there was no functional impact associated with the Veteran's symptoms other than some difficulty concentrating at work, and the April 2021 examiner found no signs or symptoms whatsoever. The Veteran is competent to report readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds the Veteran's consistent reports that he has experienced chronic indigestion, chest pain, drainage in the throat and heartburn to be credible. However, even with the Veteran's own lay testimony, there is no indication that the Veteran experienced regurgitation, or that his symptoms have caused considerable impairment of health. The medical evidence of record, including the VA examinations, is more specific to the nature and severity of the Veteran's disability. No examination of record is indicative that recurrent episodes of epigastric distress were more than mild in severity, or that there was considerable impairment of health or functional impact. The Board has considered whether a higher or separate rating is warranted for the Veteran's GERD with Mallory Weiss Syndrome under any other potentially applicable Diagnostic Code, and finds he is not entitled to a higher or separate rating under any other potentially applicable codes ranging from Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive. Specifically, the Board finds that the Veteran's GERD with Mallory Weiss Syndrome does not result in symptomatology that is not contemplated by Diagnostic Code 7346 and, consequently, a higher or separate rating is not warranted under any other potentially applicable Diagnostic Code other than those prohibited by regulation. The Board recognizes that the rating criteria for assessing the severity of GERD with Mallory Weiss Syndrome do not specifically contemplate the use of medication to ameliorate symptoms and that the Veteran has reported the use of medication to treat his symptoms throughout the appeal. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Nevertheless, the Board finds that, even when considering the symptoms the Veteran may experience when not aided by the ameliorative effect of medication, a higher rating is not warranted, as there is no probative evidence indicating that, absent medication, the Veteran would experience considerable or severe impairment of health. Therefore, a rating in excess of 10 percent is denied for the entirety of the appeal period. REASONS FOR REMAND 1. Entitlement to service connection for psoriasis, claimed as a result of exposure to Agent Orange is remanded. 2. Entitlement to service connection for psoriatic arthritis, claimed as a result of exposure to Agent Orange is remanded. 3. Entitlement to service connection for testicular cancer, claimed as a result of exposure to Agent Orange is remanded. When VA undertakes to obtain an examination/opinion, it must ensure that the examination/opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion/examination is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Pursuant to June 2020 Board remand instructions, the Veteran was afforded VA examinations in April 2021 to assess the nature and etiology of his claimed psoriasis, psoriatic arthritis and testicular cancer, to include in relation to claimed herbicide exposure in service. The examiner provided a negative opinion for each claimed disability, along with essentially the same rationale. Specifically, the examiner reasoned that the claimed conditions are not recognized by VA as presumptively related to herbicide exposure, and that the JSRRC was unable to provide a formal finding of herbicide exposure verification. The Board finds this rationale to be inadequate for adjudication purposes. In this regard, even without a finding of Agent Orange exposure in service, the Veteran may establish service connection on a direct basis which was not addressed by the examiner. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, certain chronic diseases, such as arthritis, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The examiner did not comment on whether the Veteran's psoriatic arthritis was manifest to a degree of 10 percent or greater within one year of separation. Furthermore, the Board notes that unfortunately, the Veteran's service treatment records are unavailable. In cases where a Veteran's service treatment records are unavailable through no fault of a veteran, there is a heightened obligation on the part of VA to assist the claimant in the development of his case, explain findings and conclusions, and to consider carefully the benefit of the doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). As such, the examiner should not base his/her opinion on a lack of documentation of inservice treatment, and must afford greater weight to the Veteran's lay statements which should be accepted as credible. Accordingly, the Board finds that remand is warranted to obtain addendum VA medical opinions. 4. Entitlement to service connection for an acquired psychiatric disability, claimed as PTSD and dysthymia, to include as secondary to service-connected GERD with Mallory-Weiss Syndrome is remanded. When VA undertakes to obtain an examination/opinion, it must ensure that the examination/opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion/examination is considered adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Pursuant to June 2020 Board remand instructions, the Veteran was afforded a VA examination in January 2021 to assess the nature and etiology of his claimed acquired psychiatric disability, to include as secondary to service-connected GERD with Mallory-Weiss Syndrome. The examiner identified several psychiatric diagnoses, including persistent depressive disorder with anxious distress and dysthymia. Pertinently, the examiner opined that the Veteran's acquired psychiatric disability is less likely than not related to service or to GERD. It was reasoned that his dysthymia is related to divorce, current financial stressors and other situational stressors. It was further reasoned that there is no evidence that the current depressive disorder is related to military service or any other service-connected medical diagnosis. It was also opined that there was no evidence of aggravation. The Board finds this opinion and rationale insufficient for adjudication purposes. In this regard, the Board notes that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The absence of evidence is insufficient to make an affirmative declaration. Here, the examiner provides the conclusory rationale that the Veteran's psychiatric disabilities are not related to service or to a service-connected disability because there is no evidence to suggest that they are. The examiner instead opined that the dysthymia is related to current stressors, without providing a rationale for this opinion either. Furthermore, no rationale was provided for the aggravation opinion other than silence of medical records. The Board reiterates that there is a heightened duty to assist the Veteran when STR's are unavailable through no fault of his own. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Accordingly, the Board finds that remand is warranted to obtain an addendum VA medical opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA and private treatment records pertinent to the claims remanded herein. 2. Thereafter, obtain addendum opinions from appropriately qualified medical providers to determine the nature and etiology of the Veteran's claimed skin conditions, to include psoriasis and psoriatic arthritis. The need for additional in-person or telehealth examination is left to the discretion of the examiner. All opinions offered must be accompanied by a clear rationale consistent with the evidence of record. (a.) The examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed psoriasis had onset during the Veteran's active service or is otherwise causally related to his service. (b.) The examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed psoriatic arthritis had onset during the Veteran's active service, within one year of separation from service, or is otherwise causally related to his service. (c.) The examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any testicular cancer had its onset during the Veteran's active service or is otherwise causally related to his service. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). The examiner is advised that the Veteran is competent to report his symptoms and history; and such reports must be considered in formulating any opinions. The examiner should provide a rationale for rejecting any reports by the Veteran. The examiner is further advised that the Veteran is entitled to heightened obligation on the part of VA to assist the claimant in the development of his case, explain findings and conclusions, and to consider carefully the benefit of the doubt rule. As such, the examiner should not base his/her opinion on a lack of documentation of inservice treatment, and must afford greater weight to the Veteran's lay statements which should be accepted as credible. 3. Forward the entire claims file to an appropriately qualified medical examiner for an opinion to determine the nature and etiology of the Veteran's acquired psychiatric disability, to include PTSD, depressive disorder with anxious distress and dysthymia. If the medical professional finds that a new examination or telehealth interview is necessary, one should be arranged. The claims file and a copy of this Remand must be reviewed by the examiner, who must respond to each of the following: (a) Identify each psychiatric disorder diagnosed during the appeal period. (b) Confirm whether any of the Veteran's claimed stressors are adequate to support a diagnosis of PTSD and whether the Veteran's symptoms are related to the claimed stressor(s). If a diagnosis of PTSD is deemed appropriate, the examiner must identify the specific stressor(s) underlying the diagnosis, and should comment upon the link between the current symptomatology and the Veteran's claimed stressor(s). (c) If the examiner determines that the clinical evidence does not support a diagnosis of PTSD, to include that the claimed stressors do not support the diagnosis, the examiner should list all diagnosed psychiatric disorders and specifically state whether it is at least as likely as not that any diagnosed psychiatric disorder, to include any diagnosed during the period on appeal, either began during or was otherwise caused by the Veteran's time in service. (d)The examiner must opine whether it is at least as likely as not (i.e. a 50 percent probability or more) that the Veteran's acquired psychiatric disability was caused by the Veteran's service-connected GERD with Mallory-Weiss Syndrome. (e) The examiner must opine whether it is at least as likely as not (i.e. a 50 percent probability or more) that the Veteran's acquired psychiatric disability was aggravated by the Veteran's service-connected GERD with Mallory-Weiss Syndrome. Any opinion offered should be accompanied by a clear rationale consistent with the evidence of record. The examiner must address the Veteran's lay testimony of record. If the examiner finds it impossible to provide any requested opinion without resort to pure speculation, he or she must so indicate and explain why such a finding is made. There is a heightened duty to assist the Veteran when STR's are unavailable through no fault of his own. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.